Design of an Aircrew Scheduling Decision Aid for the 6916th Electronic Security Squadron.

DTIC Science & Technology

1987-06-01

Security Classification) Design of an Aircrew Scheduling Decision Aid for the 6916th Electronic Security Squadron 12. PERSONAL AUTHOR(S) Thomas J. Kopf...Because of the great number of possible scheduling alternatives, it is difficult to find an optimal solution to-the scheduling problem. Additionally...changes to the original schedule make it even more difficult to find an optimal solution. The emergence of capable microcompu- ters, decision support

[Evidence-based Risk and Benefit Communication for Shared Decision Making].

PubMed

Nakayama, Takeo

2018-01-01

　Evidence-based medicine (EBM) can be defined as "the integration of the best research evidence with clinical expertise and a patient's unique values and circumstances". However, even with the best research evidence, many uncertainties can make clinical decisions difficult. As the social requirement of respecting patient values and preferences has been increasingly recognized, shared decision making (SDM) and consensus development between patients and clinicians have attracted attention. SDM is a process by which patients and clinicians make decisions and arrive at a consensus through interactive conversations and communications. During the process of SDM, patients and clinicians share information with each other on the goals they hope to achieve and responsibilities in meeting those goals. From the clinician's standpoint, information regarding the benefits and risks of potential treatment options based on current evidence and professional experience is provided to patients. From the patient's standpoint, information on personal values, preferences, and social roles is provided to clinicians. SDM is a sort of "wisdom" in the context of making autonomous decisions in uncertain, difficult situations through interactions and cooperation between patients and clinicians. Joint development of EBM and SDM will help facilitate patient-clinician relationships and improve the quality of healthcare.

Hart-Devlin revisited: law, morality and consent in parenthood.

PubMed

Moss, Kate; Hughes, Rowland

2011-04-01

The debate about law and morality is not new but changing social structures and advances in science, medicine and technology have impacted the decisions courts have to make. Within the fast-changing societies of the 21st century, is judicial decision-making cognisant of these advances and how do the judiciary currently reconcile difficult emergent issues concerning law, science and morality? The dilemma of decision-making regarding frozen embryos, the gametes of deceased donors and the issue of consent is analysed by reference to recent case law and the problem of decision-making in relation to the newly possible.

Eye Tracking and Pupillometry are Indicators of Dissociable Latent Decision Processes

PubMed Central

Cavanagh, James F.; Wiecki, Thomas V.; Kochar, Angad; Frank, Michael J.

2014-01-01

Can you predict what someone is going to do just by watching them? This is certainly difficult: it would require a clear mapping between observable indicators and unobservable cognitive states. In this report we demonstrate how this is possible by monitoring eye gaze and pupil dilation, which predict dissociable biases during decision making. We quantified decision making using the Drift Diffusion Model (DDM), which provides an algorithmic account of how evidence accumulation and response caution contribute to decisions through separate latent parameters of drift rate and decision threshold, respectively. We used a hierarchical Bayesian estimation approach to assess the single trial influence of observable physiological signals on these latent DDM parameters. Increased eye gaze dwell time specifically predicted an increased drift rate toward the fixated option, irrespective of the value of the option. In contrast, greater pupil dilation specifically predicted an increase in decision threshold during difficult decisions. These findings suggest that eye tracking and pupillometry reflect the operations of dissociated latent decision processes. PMID:24548281

Making difficult decisions: Immigrants' experiences of employment preparation and participation.

PubMed

Huot, Suzanne; Chen, Xiaojie; King, Christiana; Painter-Zykmund, Ellen; Watt, Kaitlin

2016-06-13

Immigrants engage in complex integration processes that are mediated through daily occupations. A central element of socio-economic integration relates to labor market preparation and participation, including job searching, learning cultural values in the workplace, pursuing credential recognition and engaging in volunteering roles and paid employment. To examine how immigrants experienced occupations relating to preparing for, seeking, and gainingemployment. A secondary analysis using whole text analysis and line-by-line coding of twenty verbatim transcripts from interviews held with ten recently arrived immigrants to London, Ontario, Canada. Sessions consisted of a narrative interview, creation of an occupational map and a semi-structured follow-up interview. The participants' employment related occupations were characterized by the overarching theme of 'making difficult decisions'. This main theme was connected to four related sub-themes: 1) mechanisms of exclusion, 2) learning the host country's culture, 3) the influence of one's outlook on the decisions made, and 4) accessing support. This study identifies factors influencing immigrants' experiences of labor market preparation and participation. 'Making difficult decisions' was faced by all participants throughout the process of becoming part of the Canadian workforce and, ultimately, society at large.

Teaching the Ethics of Biology.

ERIC Educational Resources Information Center

Johansen, Carol K.; Harris, David E.

2000-01-01

Points out the challenges of educating students about bioethics and the limited training of many biologists on ethics. Discusses the basic principles of ethics and ethical decision making as applied to biology. Explains the models of ethical decision making that are often difficult for students to determine where to begin analyzing. (Contains 28…

Implementing a Quality Needs Assessment

ERIC Educational Resources Information Center

Cuiccio, Cary

2012-01-01

Districts nationwide are facing budget cuts that, to some, feel more like funding cliffs. Accordingly, school teams are re-examining their personnel, programs, and schedules so that they can make difficult decisions about where to spend resources to realize the greatest improvement. The principals who are able to make decisions with data from…

The Effect of Multimedia Replacing Text in Resident Clinical Decision-Making Assessment

ERIC Educational Resources Information Center

Chang, Todd P.; Schrager, Sheree M.; Rake, Alyssa J.; Chan, Michael W.; Pham, Phung K.; Christman, Grant

2017-01-01

Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text…

Gender Equity, Sport Sponsorship, and Participation

ERIC Educational Resources Information Center

Yiamouyiannis, Athena

2009-01-01

As the pressure to win in select collegiate sports escalates, financial pressures mount, and the need to comply with Title IX regulations and gender equity policies continues, athletics administrators are faced with having to make difficult decisions regarding their sport programs. To assist in the decision-making process regarding sport programs,…

Development of a support tool for complex decision-making in the provision of rural maternity care.

PubMed

Hearns, Glen; Klein, Michael C; Trousdale, William; Ulrich, Catherine; Butcher, David; Miewald, Christiana; Lindstrom, Ronald; Eftekhary, Sahba; Rosinski, Jessica; Gómez-Ramírez, Oralia; Procyk, Andrea

2010-02-01

Decisions in the organization of safe and effective rural maternity care are complex, difficult, value laden and fraught with uncertainty, and must often be based on imperfect information. Decision analysis offers tools for addressing these complexities in order to help decision-makers determine the best use of resources and to appreciate the downstream effects of their decisions. To develop a maternity care decision-making tool for the British Columbia Northern Health Authority (NH) for use in low birth volume settings. Based on interviews with community members, providers, recipients and decision-makers, and employing a formal decision analysis approach, we sought to clarify the influences affecting rural maternity care and develop a process to generate a set of value-focused objectives for use in designing and evaluating rural maternity care alternatives. Four low-volume communities with variable resources (with and without on-site births, with or without caesarean section capability) were chosen. Physicians (20), nurses (18), midwives and maternity support service providers (4), local business leaders, economic development officials and elected officials (12), First Nations (women [pregnant and non-pregnant], chiefs and band members) (40), social workers (3), pregnant women (2) and NH decision-makers/administrators (17). We developed a Decision Support Manual to assist with assessing community needs and values, context for decision-making, capacity of the health authority or healthcare providers, identification of key objectives for decision-making, developing alternatives for care, and a process for making trade-offs and balancing multiple objectives. The manual was deemed an effective tool for the purpose by the client, NH. Beyond assisting the decision-making process itself, the methodology provides a transparent communication tool to assist in making difficult decisions. While the manual was specifically intended to deal with rural maternity issues, the NH decision-makers feel the method can be easily adapted to assist decision-making in other contexts in medicine where there are conflicting objectives, values and opinions. Decisions on the location of new facilities or infrastructure, or enhancing or altering services such as surgical or palliative care, would be examples of complex decisions that might benefit from this methodology.

Development of a Support Tool for Complex Decision-Making in the Provision of Rural Maternity Care

PubMed Central

Hearns, Glen; Klein, Michael C.; Trousdale, William; Ulrich, Catherine; Butcher, David; Miewald, Christiana; Lindstrom, Ronald; Eftekhary, Sahba; Rosinski, Jessica; Gómez-Ramírez, Oralia; Procyk, Andrea

2010-01-01

Context: Decisions in the organization of safe and effective rural maternity care are complex, difficult, value laden and fraught with uncertainty, and must often be based on imperfect information. Decision analysis offers tools for addressing these complexities in order to help decision-makers determine the best use of resources and to appreciate the downstream effects of their decisions. Objective: To develop a maternity care decision-making tool for the British Columbia Northern Health Authority (NH) for use in low birth volume settings. Design: Based on interviews with community members, providers, recipients and decision-makers, and employing a formal decision analysis approach, we sought to clarify the influences affecting rural maternity care and develop a process to generate a set of value-focused objectives for use in designing and evaluating rural maternity care alternatives. Setting: Four low-volume communities with variable resources (with and without on-site births, with or without caesarean section capability) were chosen. Participants: Physicians (20), nurses (18), midwives and maternity support service providers (4), local business leaders, economic development officials and elected officials (12), First Nations (women [pregnant and non-pregnant], chiefs and band members) (40), social workers (3), pregnant women (2) and NH decision-makers/administrators (17). Results: We developed a Decision Support Manual to assist with assessing community needs and values, context for decision-making, capacity of the health authority or healthcare providers, identification of key objectives for decision-making, developing alternatives for care, and a process for making trade-offs and balancing multiple objectives. The manual was deemed an effective tool for the purpose by the client, NH. Conclusions: Beyond assisting the decision-making process itself, the methodology provides a transparent communication tool to assist in making difficult decisions. While the manual was specifically intended to deal with rural maternity issues, the NH decision-makers feel the method can be easily adapted to assist decision-making in other contexts in medicine where there are conflicting objectives, values and opinions. Decisions on the location of new facilities or infrastructure, or enhancing or altering services such as surgical or palliative care, would be examples of complex decisions that might benefit from this methodology. PMID:21286270

Understanding Patenting Decisions: A Classroom Exercise

ERIC Educational Resources Information Center

Bernard, John C.; Yiannaka, Amalia

2010-01-01

Although many students have some knowledge of patents, it can be difficult for them to understand the components of an innovator's decision-making process. Key issues, such as whether to patent or to use trade secrecy, how broad a scope to claim, and what to do in the event of patent infringement, can be difficult to grasp from a standard lecture.…

Making Things Difficult in Lexical Decision: The Impact of Pseudohomophones and Transposed-Letter Nonwords on Frequency and Semantic Priming Effects

ERIC Educational Resources Information Center

Lupker, Stephen J.; Pexman, Penny M.

2010-01-01

Performance in a lexical decision task is crucially dependent on the difficulty of the word-nonword discrimination. More wordlike nonwords cause not only a latency increase for words but also, as reported by Stone and Van Orden (1993), larger word frequency effects. Several current models of lexical decision making can explain these types of…

"I Think We Should Take This Offline...": Conversational Patterns that Undermine Effective Decision Making in Action Learning Sets

ERIC Educational Resources Information Center

Donovan, Paul

2011-01-01

Collective decision making is an increasing requirement in organizations where the emphasis is on team work at every level. It is, however, very complex and difficult to achieve in practice. Too frequently, important discussions are bypassed or, while the majority of the meeting participants remain mute, decisions are being made by a vocal few. In…

Student's Local Top-Up Higher Education Choices

ERIC Educational Resources Information Center

Agbola, Frank W.; Cheng, Calvin

2017-01-01

Making decisions about education choices is challenging and difficult for students. Utilising the theory of reasoned action, we specify and estimate a conceptual framework that captures the cognitive process of decision making of students in choosing top-up higher degrees in Hong Kong. Top-up higher or bachelor's degrees are top-up undergraduate…

Security Design Flaws That Affect Usability in Online Banking

ERIC Educational Resources Information Center

Gurlen, Stephanie

2013-01-01

As the popularity of online banking Websites has increased, the security of these sites has become increasingly critical as attacks against these sites are on the rise. However, the design decisions made during construction of the sites could make usability more difficult, where the user has difficulty making good security decisions. This study…

The Role of Patients: Shared Decision-Making.

PubMed

Beers, Emily; Lee Nilsen, Marci; Johnson, Jonas T

2017-08-01

Shared decision-making affords patients and their families the autonomy to make difficult decisions after receiving comprehensive information about medical facts and treatment options. It is essential that patients' values are respected. The essential steps include first informing patients of the need for a decision, then explaining the various facts involved; after which, it is important to elicit patients' preferences and goals. Once the treatment options and outcomes important to patients are identified, an actual decision can be made. This activity is complex and requires a commitment of time and is enhanced through employment of a multidisciplinary team approach. Copyright © 2017 Elsevier Inc. All rights reserved.

Medical futility in children's nursing: making end-of-life decisions.

PubMed

Brien, Irene O; Duffy, Anita; Shea, Ellen O

Caring for infants at end of life is challenging and distressing for parents and healthcare professionals, especially in relation to making decisions regarding withholding or withdrawal of treatment. The concept of medical futility must be considered under these circumstances. Parents and healthcare professionals should be involved together in making these difficult decisions. However, for some parents, emotions and guilt often are unbearable and, understandably, parents can be reluctant to make a decision. Despite the recognition of parental autonomy, if parents disagree with a decision made by medical staff, the case will be referred to and solved by the courts. The courts' decisions are often based on the best interest of the child. In this article, the authors discuss the concepts of 'parental autonomy' and 'the child's best interests' when determining medical futility for infants or neonates. The role of the nurse when caring for the dying child and their family is multifaceted. While nurses do not have a legitimate role in decision making at the end of life, it is often nurses who, through their advocacy role, inform doctors about parents' wishes and it is often nurses who support parents during this difficult time. Furthermore, nurses caring for dying children should be familiar to the family, experienced in end-of-life care and comfortable talking to parents about death and dying and treatment choices. Children's nurses therefore require advanced communication skills and an essential understanding of the ethical and legal knowledge relating to medical futility in end-of-life children's nursing.

[Treatment Decision-Making Process of Cancer Patients].

PubMed

Lee, Shiu-Yu C Katie

2016-10-01

The decision-making process that is used by cancer patients to determine their treatment has become more multi-foci, difficult and complicated in recent years. This has in part been attributed to the increasing incidence rate of cancer in Taiwan and the rapid development of medical technologies and treatment modalities. Oncology nurses must assist patients and family to make informed and value-based treatment decisions. Decision-making is an information process that involves appraising one's own expectation and values based on his/her knowledge on cancer and treatment options. Because cancer treatment involves risks and uncertainties, and impacts quality of life, the treatment decision-making for cancer is often stressful, or even conflicting. This paper discusses the decision-making behaviors of cancer patients and the decisional conflict, participation, and informational needs that are involved in cancer treatment. The trend toward shared decision-making and decisional support will be also explored in order to facilitate the future development of appropriate clinical interventions and research.

Tough Choices for Teachers: Ethical Challenges in Today's Schools and Classrooms

ERIC Educational Resources Information Center

Infantino, Robert; Wilke, Rebecca

2009-01-01

From lesson-planning to instructional practice to classroom management, teachers must make choices constantly and consistently. Sometimes these decisions are easy, but there are some decisions that are very difficult. Such delicate decisions often arise in the world of education and may be detrimental to one's career. Thoughtful decision-making…

Eye tracking and pupillometry are indicators of dissociable latent decision processes.

PubMed

Cavanagh, James F; Wiecki, Thomas V; Kochar, Angad; Frank, Michael J

2014-08-01

Can you predict what people are going to do just by watching them? This is certainly difficult: it would require a clear mapping between observable indicators and unobservable cognitive states. In this report, we demonstrate how this is possible by monitoring eye gaze and pupil dilation, which predict dissociable biases during decision making. We quantified decision making using the drift diffusion model (DDM), which provides an algorithmic account of how evidence accumulation and response caution contribute to decisions through separate latent parameters of drift rate and decision threshold, respectively. We used a hierarchical Bayesian estimation approach to assess the single trial influence of observable physiological signals on these latent DDM parameters. Increased eye gaze dwell time specifically predicted an increased drift rate toward the fixated option, irrespective of the value of the option. In contrast, greater pupil dilation specifically predicted an increase in decision threshold during difficult decisions. These findings suggest that eye tracking and pupillometry reflect the operations of dissociated latent decision processes. PsycINFO Database Record (c) 2014 APA, all rights reserved.

Ethical Decision Making: A Teaching and Learning Model for Graduate Students and New Professionals

ERIC Educational Resources Information Center

McDonald, William M.; Ebelhar, Marcus Walker; Orehovec, Elizabeth R.; Sanderson, Robyn H.

2006-01-01

Student affairs practitioners are inundated with a variety of ethical considerations when making day-to-day decisions regarding the welfare of students and colleagues. There is every reason to believe that confronting ethical issues will be an increasingly difficult issue for student affairs professionals in the future. This article provides a…

The Allied Health Care Professional's Role in Assisting Medical Decision Making at the End of Life

ERIC Educational Resources Information Center

Lambert, Heather

2012-01-01

As a patient approaches the end of life, he or she faces a number of very difficult medical decisions. Allied health care professionals, including speech-language pathologists (SLPs) and occupational therapists (OTs), can be instrumental in assisting their patients to make advance care plans, although their traditional job descriptions do not…

Dark Matter: The "Gravitational Pull" of Maternalist Discourses on Politicians' Decision Making for Early Childhood Policy in Australia

ERIC Educational Resources Information Center

Bown, Kathryn; Sumsion, Jennifer; Press, Frances

2011-01-01

The article reports on a study investigating influences on Australian politicians' decision making for early childhood education and care (ECEC) policy. The astronomical concept of dark matter is utilised as a metaphor for considering normalising, and therefore frequently difficult to detect and disrupt, influences implicated in politicians'…

A Navy Officer Assignment Model

DTIC Science & Technology

1982-03-01

replace the routine administrative tasks required of both assignment and placement officers without reducing their role in making the essential decisions ...individual has no desire to serve there. This last aspect of the detailer’s job can be the most difficult, since he must both make the decision of who is...34Billet Fill Decision " has been made by a third party, an officer whose primary responsibility is to oversee this program, according to the previous

Improving Access to and Understanding of Regulations through Taxonomies

ERIC Educational Resources Information Center

Cheng, Chin Pang; Lau. Gloria T.; Law, Kincho H.; Pan, Jiayi; Jones, Albert

2009-01-01

Industrial taxonomies have the potential to automate information retrieval, facilitate interoperability and, most importantly, improve decision making - decisions that must comply with existing government regulations and codes of practice. However, it is difficult to find those regulations and codes most relevant to a particular decision, even…

The emergency patient's participation in medical decision-making.

PubMed

Wang, Li-Hsiang; Goopy, Suzanne; Lin, Chun-Chih; Barnard, Alan; Han, Chin-Yen; Liu, Hsueh-Erh

2016-09-01

The purpose of this research was to explore the medical decision-making processes of patients in emergency departments. Studies indicate that patients should be given enough time to acquire relevant information and receive adequate support when they need to make medical decisions. It is difficult to satisfy these requirements in emergency situations. Limited research has addressed the topic of decision-making among emergency patients. This qualitative study used a broadly defined grounded theory approach to explore decision-making in an emergency department in Taiwan. Thirty emergency patients were recruited between June and December 2011 for semi-structured interviews that were audio-taped and transcribed verbatim. The study identified three stages in medical decision-making by emergency patients: predecision (interpreting the problem); decision (a balancing act) and postdecision (reclaiming the self). Transference was identified as the core category and pattern of behaviour through which patients resolved their main concerns. This transference around decision-making represents a type of bricolage. The findings fill a gap in knowledge about the decision-making process among emergency patients. The results inform emergency professionals seeking to support patients faced with complex medical decision-making and suggest an emphasis on informed patient decision-making, advocacy, patient-centred care and in-service education of health staff. © 2016 John Wiley & Sons Ltd.

What is known about parents' treatment decisions? A narrative review of pediatric decision making.

PubMed

Lipstein, Ellen A; Brinkman, William B; Britto, Maria T

2012-01-01

With the increasing complexity of decisions in pediatric medicine, there is a growing need to understand the pediatric decision-making process. To conduct a narrative review of the current research on parent decision making about pediatric treatments and identify areas in need of further investigation. Articles presenting original research on parent decision making were identified from MEDLINE (1966-6/2011), using the terms "decision making," "parent," and "child." We included papers focused on treatment decisions but excluded those focused on information disclosure to children, vaccination, and research participation decisions. We found 55 papers describing 52 distinct studies, the majority being descriptive, qualitative studies of the decision-making process, with very limited assessment of decision outcomes. Although parents' preferences for degree of participation in pediatric decision making vary, most are interested in sharing the decision with the provider. In addition to the provider, parents are influenced in their decision making by changes in their child's health status, other community members, prior knowledge, and personal factors, such as emotions and faith. Parents struggle to balance these influences as well as to know when to include their child in decision making. Current research demonstrates a diversity of influences on parent decision making and parent decision preferences; however, little is known about decision outcomes or interventions to improve outcomes. Further investigation, using prospective methods, is needed in order to understand how to support parents through the difficult treatment decisions.

Stress and Aeronautical Team Decision Making: Strengthening the Weak Links

NASA Technical Reports Server (NTRS)

Orasanu, Judith; Rosekind, Mark R. (Technical Monitor)

1996-01-01

A model that characterizes pilots'decision making in flight will be presented. Elements of the model that appear most vulnerable to stress will be examined in light of accidents and incidents. The model includes two major components: Situation assessment and choice of a course of action. While based on Klein's Recognition-Primed Decision Making, it is tailored to the aviation environment which includes certain features that may be common to other domains: Primarily, aviation is highly proceduralized and options are generally well known. What appears to make decisions difficult are ambiguity, time pressure, and risk. In addition, decisions must often be made while carrying out the standard procedures of flight, including checklists, review of approach plates, standard briefings, and communication with air traffic controllers or cabin crew. The effects of stressors on decision making by pilots with varying levels of expertise will be explored, along with strategies for strengthening the weak links.

Experts in offside decision making learn to compensate for their illusory perceptions.

PubMed

Put, Koen; Baldo M, V C; Cravo, André M; Wagemans, Johan; Helsen, Werner F

2013-12-01

In association football, the flash-lag effect appears to be a viable explanation for erroneous offside decision making. Due to this spatiotemporal illusion, assistant referees (ARs) perceive the player who receives the ball ahead of his real position. In this experiment, a laboratory decision-making task was used to demonstrate that international top-class ARs, compared with amateur soccer players, do not have superior perceptual sensitivity. They clearly modify their decision criterion according to the contextual needs and, therefore, show a higher response bias toward not responding to the stimulus, in particular in the most difficult situations. Thus, international ARs show evidence for response-level compensation, resulting in a specific cost (i.e., more misses), which clearly reflects the use of particular (cognitive) strategies. In summary, it appears that experts in offside decision making can be distinguished from novices more on the cognitive or decision-making level than on the perceptual level.

Considerations of informed consent and decision-making competence in older adults with cognitive impairment.

PubMed

Mayo, Ann M; Wallhagen, Margaret I

2009-04-01

Including older adults with cognitive impairment in research studies is necessary to ensure that interventions designed to improve care are effective for all older adults. However, issues related to capacity to consent raise many difficult questions that nurse researchers must address. Protecting vulnerable participants while simultaneously maintaining autonomy and moving important research forward can be challenging. Assessing the decision-making abilities of understanding, appreciation, reasoning, and expressing a choice is an important aspect of determining decision-making capacity. Yet although this is the prominent rational method for judging decision-making competence, it does not take into consideration the importance of culture, values, and emotions. This article focuses on the assessment of decision-making capacity to consent, recommendations for obtaining informed consent in older adults with cognitive impairment, the use of surrogate decision makers, strategies to maximize research participation, and directions for future research. Copyright 2009, SLACK Incorporated.

Assessment of Healthcare Decision-making Capacity

PubMed Central

Palmer, Barton W.; Harmell, Alexandrea L.

2016-01-01

It is often necessary for neuropsychologists, clinical psychologists, and other healthcare professionals to assess an individual's capacity to consent to treatment related to healthcare. This task can be challenging and requires a delicate balance of both respect for individuals' autonomy, as well as the protection of individuals with diminished capacity to make an autonomous decision. The purpose of the present review is to provide an overview of the conceptual model of decisional capacity as well as a brief summary of some of the currently available instruments designed to help evaluate medical decision making. In addition, current empirical literature on the relationship between neuropsychological abilities and decision-making capacity is discussed and a brief set of recommendations is provided to further aid clinicians or consultants when they are required to complete the ethically important but difficult task of making determinations about healthcare decision-making capacity. PMID:27551024

Planning a school physics experiment

NASA Astrophysics Data System (ADS)

Blasiak, Wladyslaw

1986-09-01

One is continually faced with the need to make decisions; physics, might form the vehicle for teaching the difficult art of decision making. Teachers should direct the abilities and skills of their students toward optimising the choices with which they are faced. Examples of such choices occur in the design of physics experiments and this therefore offers a good opportunity for such instruction.

The Demands of Decentralization: Skills and Knowledge for Leaders in Restructured Schools

ERIC Educational Resources Information Center

Gok, Kubilay; Peterson, Kent D.; Warren, Valli D.

2005-01-01

One of the most visible and widespread of the current educational reforms is the attempt to decentralize authority to schools and to involve teachers and others in shared decision making. Often occurring together as site-based shared decision making (SBDM), this reform is turning out to be more difficult to implement than once thought. Few noted…

Proof in the Pattern: Librarians Follow the Corporate Sector toward More Data-Driven Management

ERIC Educational Resources Information Center

Nicholson, Scott

2006-01-01

As demands on libraries continue to grow, outpacing budget increases, more librarians are forced to make difficult decisions about what materials and services stay and go. Charles R. McClure has written that many librarians use an "adhocracy" method to make these decisions, relying on no data or simple aggregates in determining a course of action.…

Assessing the role of evidence in patients' evaluation of complementary therapies: a quality study.

PubMed

Verhoef, Marja J; Mulkins, Andrea; Carlson, Linda E; Hilsden, Robert J; Kania, Anna

2007-12-01

Making the decision to use complementary and alternative medicine (CAM) for cancer treatment is difficult in light of the limited available evidence for these treatments. It is unclear how patients use evidence to make these decisions. (1) Describe the type of information about CAM that cancer patients use in their decision making; (2) understand why certain types of information about CAM are accepted as evidence by cancer patients; and (3) explore the role of scientific evidence in treatment decision making. A qualitative study design using in-depth semistructured interviews with cancer patients attending 4 conventional and integrative health care institutions in Alberta and British Columbia, Canada, was used. Twenty-seven patients were interviewed. Patients sought CAM information from a range of sources, including the Internet, health care providers, friends, relatives, and newspapers. Many expressed frustration about the overwhelming amount of available information and found it difficult to identify reliable information. Information was described as reliable if it supported them in arriving at a decision about CAM. Types of information participants identified included anecdotes, expert opinion, gut feeling, popular literature, scientific evidence, testimonials, advertising and trial and error. Profound differences were found between new CAM users, experienced CAM users, and users with late-stage cancer in type of information sought, the role of scientific evidence in decision making, and overall information needs. Although this was a relatively small qualitative study, the results suggest that (1) many patients do not value scientific evidence as highly as conventional providers and (2) it is important for clinicians and other information providers to be aware of the different types of information that patients seek out and access when making choices and decisions regarding CAM treatments and why they seek out these sources.

In search of tools to aid logical thinking and communicating about medical decision making.

PubMed

Hunink, M G

2001-01-01

To have real-time impact on medical decision making, decision analysts need a wide variety of tools to aid logical thinking and communication. Decision models provide a formal framework to integrate evidence and values, but they are commonly perceived as complex and difficult to understand by those unfamiliar with the methods, especially in the context of clinical decision making. The theory of constraints, introduced by Eliyahu Goldratt in the business world, provides a set of tools for logical thinking and communication that could potentially be useful in medical decision making. The author used the concept of a conflict resolution diagram to analyze the decision to perform carotid endarterectomy prior to coronary artery bypass grafting in a patient with both symptomatic coronary and asymptomatic carotid artery disease. The method enabled clinicians to visualize and analyze the issues, identify and discuss the underlying assumptions, search for the best available evidence, and use the evidence to make a well-founded decision. The method also facilitated communication among those involved in the care of the patient. Techniques from fields other than decision analysis can potentially expand the repertoire of tools available to support medical decision making and to facilitate communication in decision consults.

Advance Directive in End of Life Decision-Making among the Yoruba of South-Western Nigeria

PubMed Central

Jegede, Ayodele Samuel; Adegoke, Olufunke Olufunsho

2017-01-01

End-of-life decision making is value-laden within the context of culture and bioethics. Also, ethics committee role is difficult to understand on this, thus need for ethnomethodological perspective in an expanding bioethical age. Anthropological approach was utilized to document Yoruba definition and perspective of death, cultural beliefs about end-of-life decision making, factors influencing it and ethics committee role. Interviews were conducted among selected Yoruba resident in Akinyele LGA, Oyo State, Nigeria. Content analytical approach was used for data analysis. Yoruba culture, death is socially constructed having spiritual, physical and social significance. Relationship between the dying and significant others influences decision making. Hierarchy of authority informs implementing traditional advance directive. Socialization, gender, patriarchy, religious belief and tradition are major considerations in end-of-life decision making. Awareness, resource allocation and advocacy are important ethics committees’ roles. Further research into cultural diversity of end-of-life decision making will strengthen ethical practice in health care delivery. PMID:28344984

Advance Directive in End of Life Decision-Making among the Yoruba of South-Western Nigeria.

PubMed

Jegede, Ayodele Samuel; Adegoke, Olufunke Olufunsho

2016-11-01

End-of-life decision making is value-laden within the context of culture and bioethics. Also, ethics committee role is difficult to understand on this, thus need for ethnomethodological perspective in an expanding bioethical age. Anthropological approach was utilized to document Yoruba definition and perspective of death, cultural beliefs about end-of-life decision making, factors influencing it and ethics committee role. Interviews were conducted among selected Yoruba resident in Akinyele LGA, Oyo State, Nigeria. Content analytical approach was used for data analysis. Yoruba culture, death is socially constructed having spiritual, physical and social significance. Relationship between the dying and significant others influences decision making. Hierarchy of authority informs implementing traditional advance directive. Socialization, gender, patriarchy, religious belief and tradition are major considerations in end-of-life decision making. Awareness, resource allocation and advocacy are important ethics committees' roles. Further research into cultural diversity of end-of-life decision making will strengthen ethical practice in health care delivery.

What Is Known about Parents’ Treatment Decisions? A Narrative Review of Pediatric Decision Making

PubMed Central

Lipstein, Ellen A.; Brinkman, William B.; Britto, Maria T.

2013-01-01

Background With the increasing complexity of decisions in pediatric medicine, there is a growing need to understand the pediatric decision-making process. Objective To conduct a narrative review of the current research on parent decision making about pediatric treatments and identify areas in need of further investigation. Methods Articles presenting original research on parent decision making were identified from MEDLINE (1966–6/2011), using the terms “decision making,” “parent,” and “child.” We included papers focused on treatment decisions but excluded those focused on information disclosure to children, vaccination, and research participation decisions. Results We found 55 papers describing 52 distinct studies, the majority being descriptive, qualitative studies of the decision-making process, with very limited assessment of decision outcomes. Although parents’ preferences for degree of participation in pediatric decision making vary, most are interested in sharing the decision with the provider. In addition to the provider, parents are influenced in their decision making by changes in their child’s health status, other community members, prior knowledge, and personal factors, such as emotions and faith. Parents struggle to balance these influences as well as to know when to include their child in decision making. Conclusions Current research demonstrates a diversity of influences on parent decision making and parent decision preferences; however, little is known about decision outcomes or interventions to improve outcomes. Further investigation, using prospective methods, is needed in order to understand how to support parents through the difficult treatment decisions. PMID:21969136

'It ain't what you do it's the way that you do it': lessons for health care from decommissioning of older people's services.

PubMed

Robinson, Suzanne; Glasby, Jon; Allen, Kerry

2013-11-01

Public sector organisations are facing one of the most difficult financial periods in history and local decision-makers are tasked with making tough rationing decisions. Withdrawing or limiting services is an emotive and complex task and something the National Health Service has always found difficult. Over time, local authorities have gained significant experience in the closure of care homes - an equally complex and controversial issue. Drawing on local knowledge and best practice examples, this article highlights lessons and themes identified by those decommissioning care home services. We believe that such lessons are relevant to those making disinvestment decisions across public sector services, including health-care. The study employed semi-structured interviews with 12 Directors of Adult Social Services who had been highlighted nationally as having extensive experience of home closures. Interviews were conducted over a 2-week period in March 2011. Results from the study found that having local policy guidance that is perceived as fair and reasonable was advocated by those involved in home closures. Many local policies had evolved over time and had often been developed following experiences of home closures (both good and bad). Decisions to close care home services require a combination of strong leadership, clear strategic goals, a fair decision-making process, strong evidence of the need for change and good communication, alongside wider stakeholder engagement and support. The current financial challenge means that public sector organisations need to make tough choices on investment and disinvestment decisions. Any such decisions need to be influenced by what we know constitutes best practice. Sharing lessons and experiences within and between sectors could well inform and develop decision-making practices. © 2013 John Wiley & Sons Ltd.

The neural basis of rationalization: cognitive dissonance reduction during decision-making.

PubMed

Jarcho, Johanna M; Berkman, Elliot T; Lieberman, Matthew D

2011-09-01

People rationalize the choices they make when confronted with difficult decisions by claiming they never wanted the option they did not choose. Behavioral studies on cognitive dissonance provide evidence for decision-induced attitude change, but these studies cannot fully uncover the mechanisms driving the attitude change because only pre- and post-decision attitudes are measured, rather than the process of change itself. In the first fMRI study to examine the decision phase in a decision-based cognitive dissonance paradigm, we observed that increased activity in right-inferior frontal gyrus, medial fronto-parietal regions and ventral striatum, and decreased activity in anterior insula were associated with subsequent decision-related attitude change. These findings suggest the characteristic rationalization processes that are associated with decision-making may be engaged very quickly at the moment of the decision, without extended deliberation and may involve reappraisal-like emotion regulation processes.

The neural basis of rationalization: cognitive dissonance reduction during decision-making

PubMed Central

Jarcho, Johanna M.; Berkman, Elliot T.

2011-01-01

People rationalize the choices they make when confronted with difficult decisions by claiming they never wanted the option they did not choose. Behavioral studies on cognitive dissonance provide evidence for decision-induced attitude change, but these studies cannot fully uncover the mechanisms driving the attitude change because only pre- and post-decision attitudes are measured, rather than the process of change itself. In the first fMRI study to examine the decision phase in a decision-based cognitive dissonance paradigm, we observed that increased activity in right-inferior frontal gyrus, medial fronto-parietal regions and ventral striatum, and decreased activity in anterior insula were associated with subsequent decision-related attitude change. These findings suggest the characteristic rationalization processes that are associated with decision-making may be engaged very quickly at the moment of the decision, without extended deliberation and may involve reappraisal-like emotion regulation processes. PMID:20621961

Bringing freight components into statewide and regional travel demand forecasting: part 1 : final report.

DOT National Transportation Integrated Search

2016-01-01

Transportation decision makers have the difficult task of investment decision making having limited resources while : maximizing benefit to the transportation system. Given the growth in freight transport and its importance to national, : state, and ...

Impact of Robotic Surgery on Decision Making: Perspectives of Surgical Teams

PubMed Central

Randell, Rebecca; Alvarado, Natasha; Honey, Stephanie; Greenhalgh, Joanne; Gardner, Peter; Gill, Arron; Jayne, David; Kotze, Alwyn; Pearman, Alan; Dowding, Dawn

2015-01-01

There has been rapid growth in the purchase of surgical robots in both North America and Europe in recent years. Whilst this technology promises many benefits for patients, the introduction of such a complex interactive system into healthcare practice often results in unintended consequences that are difficult to predict. Decision making by surgeons during an operation is affected by variables including tactile perception, visual perception, motor skill, and instrument complexity, all of which are changed by robotic surgery, yet the impact of robotic surgery on decision making has not been previously studied. Drawing on the approach of realist evaluation, we conducted a multi-site interview study across nine hospitals, interviewing 44 operating room personnel with experience of robotic surgery to gather their perspectives on how robotic surgery impacts surgeon decision making. The findings reveal both potential benefits and challenges of robotic surgery for decision making. PMID:26958244

Impact of Robotic Surgery on Decision Making: Perspectives of Surgical Teams.

PubMed

Randell, Rebecca; Alvarado, Natasha; Honey, Stephanie; Greenhalgh, Joanne; Gardner, Peter; Gill, Arron; Jayne, David; Kotze, Alwyn; Pearman, Alan; Dowding, Dawn

2015-01-01

There has been rapid growth in the purchase of surgical robots in both North America and Europe in recent years. Whilst this technology promises many benefits for patients, the introduction of such a complex interactive system into healthcare practice often results in unintended consequences that are difficult to predict. Decision making by surgeons during an operation is affected by variables including tactile perception, visual perception, motor skill, and instrument complexity, all of which are changed by robotic surgery, yet the impact of robotic surgery on decision making has not been previously studied. Drawing on the approach of realist evaluation, we conducted a multi-site interview study across nine hospitals, interviewing 44 operating room personnel with experience of robotic surgery to gather their perspectives on how robotic surgery impacts surgeon decision making. The findings reveal both potential benefits and challenges of robotic surgery for decision making.

End-of-life issues: difficult decisions and dealing with grief.

PubMed

Loomis, Beth

2009-06-01

People face many challenging psychosocial and spiritual issues as they approach the end of their lives, and caregivers need advice on how to help them. Choosing among treatment options, handling grief, addressing unfinished business, and coping with loss of self-sufficiency are difficult for the dying person, and caregivers must deal with surrogate decision making, raw emotions in the patient and in family members, and the caregivers' own grief. Listening and coping skills are discussed.

Approaches to end-of-life decision-making in the NICU: insights from Dostoevsky's The Grand Inquisitor.

PubMed

Paris, J J; Graham, N; Schreiber, M D; Goodwin, M

2006-07-01

For many parents stopping life-sustaining medical treatment on their dying infant is psychologically impossible. Dostoevsky's insights into human behavior, particularly the fact that individuals do not want the anxiety and guilt associated with responsibility for making difficult decisions, might change the way physicians approach parents for permission to withdraw life-prolonging medical interventions on dying infants.

Behavioural and physiological effects of finely balanced decision-making in chickens.

PubMed

Davies, Anna C; Nicol, Christine J; Persson, Mia E; Radford, Andrew N

2014-01-01

In humans, more difficult decisions result in behavioural and physiological changes suggestive of increased arousal, but little is known about the effect of decision difficulty in other species. A difficult decision can have a number of characteristics; we aimed to monitor how finely balanced decisions, compared to unbalanced ones, affected the behaviour and physiology of chickens. An unbalanced decision was one in which the two options were of unequal net value (1 (Q1) vs. 6 (Q6) pieces of sweetcorn with no cost associated with either option); a finely balanced decision was one in which the options were of equal net value (i.e. hens were "indifferent" to both options). To identify hens' indifference, a titration procedure was used in which a cost (electromagnetic weight on an access door) was applied to the Q6 option, to find the individual point at which hens chose this option approximately equally to Q1 via a non-weighted door. We then compared behavioural and physiological indicators of arousal (head movements, latency to choose, heart-rate variability and surface body temperature) when chickens made decisions that were unbalanced or finely balanced. Significant physiological (heart-rate variability) and behavioural (latency to pen) differences were found between the finely balanced and balanced conditions, but these were likely to be artefacts of the greater time and effort required to push through the weighted doors. No other behavioural and physiological measures were significantly different between the decision categories. We suggest that more information is needed on when best to monitor likely changes in arousal during decision-making and that future studies should consider decisions defined as difficult in other ways.

Ethical decision-making near the end of life.

PubMed

Finucane, T E; Harper, M

1996-05-01

For ethical decision-making near the end of life, autonomy is the moral North Star. At the same time, for some treatments, the burdens so clearly outweigh benefits that physicians may make a judgment not to offer the treatment. This is often clearer in surgery. A person with colon cancer and metastases may not insist on resection of the metastases. For some reason, some treatments have escaped these logical constraints. Attempted resuscitation of a dying patient is a good example. The circumstances in which a physician may make choices on behalf of a competent, terminally-ill patient without consent, and even without notification, are hotly debated, but data suggest that physicians do so frequently. Patients who lack capacity present even more difficult challenges. Advance directives, when available, can be extremely helpful, but even with them difficult problems can remain. If advance directives have not been established, family and close friends are an obvious source of guidance. Their legal role varies in different jurisdictions; in practice, they are crucial in bedside decision-making. Guardianship and alternatives to it remain a poor last resort. Euthanasia is a very difficult problem. We believe it is semantically misleading to lump under the term "passive euthanasia" those circumstances where potentially life-sustaining treatment is withheld or withdrawn. The tension between patient autonomy and medical common sense remains unresolved within the "futility" controversy. The authors believe it serves no purpose to discuss carefully with dying patients propositions that are nonsense. At the same time, physicians must not confuse decisions about quality of life with judgements about treatment effectiveness. We believe that what many, although not all, dying patients want are physicians with intelligent compassion who can take care of them through the dying process.

Conceptual framework of knowledge management for ethical decision-making support in neonatal intensive care.

PubMed

Frize, Monique; Yang, Lan; Walker, Robin C; O'Connor, Annette M

2005-06-01

This research is built on the belief that artificial intelligence estimations need to be integrated into clinical social context to create value for health-care decisions. In sophisticated neonatal intensive care units (NICUs), decisions to continue or discontinue aggressive treatment are an integral part of clinical practice. High-quality evidence supports clinical decision-making, and a decision-aid tool based on specific outcome information for individual NICU patients will provide significant support for parents and caregivers in making difficult "ethical" treatment decisions. In our approach, information on a newborn patient's likely outcomes is integrated with the physician's interpretation and parents' perspectives into codified knowledge. Context-sensitive content adaptation delivers personalized and customized information to a variety of users, from physicians to parents. The system provides structuralized knowledge translation and exchange between all participants in the decision, facilitating collaborative decision-making that involves parents at every stage on whether to initiate, continue, limit, or terminate intensive care for their infant.

DECISION-MAKING USING EXISTING DATA

EPA Science Inventory

Decision-makers need information on cumulative and aggregate stressors as well as clear information on where problems are likely to occur in the future in order to prioritize risk management actions. The most prevasive and difficult to assess changes are the result of regional-s...

Beyond the short term : transportation asset management for long-term sustainability, accountability and performance

DOT National Transportation Integrated Search

2010-01-01

Transportation Asset Management (TAM) has long been recognized as a sound, long-term approach to managing infrastructure. It provides decision makers with a rational, long-term systematic process for making difficult and complex decisions about how t...

Information giving and decision-making in patients with advanced cancer: a systematic review.

PubMed

Gaston, Christine M; Mitchell, Geoffrey

2005-11-01

Patients with advanced, non-curable cancer face difficult decisions on further treatment, where a small increase in survival time must be balanced against the toxicity of the treatment. If patients want to be involved in these decisions, in keeping with current notions of autonomy and empowerment, they also require to be adequately informed both on the treatments proposed and on their own disease status and prognosis. A systematic review was performed on decision-making and information provision in patients with advanced cancer. Studies of interventions to improve information giving and encourage participation in decision-making were reviewed, including both randomised controlled trials and uncontrolled studies. Almost all patients expressed a desire for full information, but only about two-thirds wished to participate actively in decision-making. Higher educational level, younger age and female sex were predictive of a desire to participate in decision-making. Active decision-making was more common in patients with certain cancers (e.g. breast) than others (e.g. prostate). A number of simple interventions including question prompt sheets, audio-taping of consultations and patient decision aids have been shown to facilitate such involvement.

Emotion expression, decision-making and well-being.

PubMed

Xiao, Erte

2008-01-01

This chapter discusses the role of emotion expression in decision-making. To understand connections between emotion and decision it is helpful first to differentiate between emotion experience and emotion expression. Understanding how emotion expression influences decision-making is important as a practical matter. However, in contrast to emotion experience, economic research has paid little attention to the significance of emotion expression in decision-making. I review recent studies on emotion expression, paying specific attention to possible connections between emotion expression, punishment, fair economic exchange, and well-being. In contrast to emotions, which are typically difficult to control, I suggest that opportunities for emotion expression can feasibly be manipulated through appropriately designed policies. I further suggest that this approach may have the ability to positively affect well-being and economic outcomes. VALUE OF THE CHAPTER: The chapter provides new perspectives on how policy-makers can benefit by understanding the effect of emotion expression in decision-making. The chapter also suggests future research to improve our understanding of emotion expression.

Decisions and Macroeconomics: Development and Implementation of a Simulation Game

ERIC Educational Resources Information Center

Woltjer, Geert B.

2005-01-01

For many students macroeconomics is very abstract; it is difficult for them to imagine that the theories are fundamentally about the coordination of human decisions. The author developed a simulation game called Steer the Economy that creates the possibility for students to make the decisions of the firms that are implicit in macroeconomic models.…

Decision making under uncertainty: Recommendations for the Wildland Fire Decision Support System (WFDSS)

Treesearch

Matthew P. Thompson

2015-01-01

The management of wildfire is a dynamic, complex, and fundamentally uncertain enterprise. Fire managers face uncertainties regarding fire weather and subsequent influence on fire behavior, the effects of fire on socioeconomic and ecological resources, and the efficacy of alternative suppression actions on fire outcomes. In these types of difficult decision environments...

Risk perception & strategic decision making :general insights, a framework, and specific application to electricity generation using nuclear energy.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Brewer, Jeffrey D.

The objective of this report is to promote increased understanding of decision making processes and hopefully to enable improved decision making regarding high-consequence, highly sophisticated technological systems. This report brings together insights regarding risk perception and decision making across domains ranging from nuclear power technology safety, cognitive psychology, economics, science education, public policy, and neural science (to name a few). It forms them into a unique, coherent, concise framework, and list of strategies to aid in decision making. It is suggested that all decision makers, whether ordinary citizens, academics, or political leaders, ought to cultivate their abilities to separate themore » wheat from the chaff in these types of decision making instances. The wheat includes proper data sources and helpful human decision making heuristics; these should be sought. The chaff includes ''unhelpful biases'' that hinder proper interpretation of available data and lead people unwittingly toward inappropriate decision making ''strategies''; obviously, these should be avoided. It is further proposed that successfully accomplishing the wheat vs. chaff separation is very difficult, yet tenable. This report hopes to expose and facilitate navigation away from decision-making traps which often ensnare the unwary. Furthermore, it is emphasized that one's personal decision making biases can be examined, and tools can be provided allowing better means to generate, evaluate, and select among decision options. Many examples in this report are tailored to the energy domain (esp. nuclear power for electricity generation). The decision making framework and approach presented here are applicable to any high-consequence, highly sophisticated technological system.« less

Risky communication: pitfalls in counseling about risk, and how to avoid them.

PubMed

O'Doherty, K; Suthers, G K

2007-08-01

A genetic counselor is often faced with the difficult task of conveying a set of complex and highly abstract factors associated with the client's risk of developing a familial disorder. The client is faced with the even more difficult task of making significant health-related decisions about an event which may or may not eventuate. Although there is a large corpus of research on this topic, much of the knowledge on risk communication is difficult to apply in a practical context. In this paper we draw together some insights on risk communication and decision-making under conditions of uncertainty, and apply them directly to the problem of communicating familial cancer risk. In particular, we focus on the distinction between individual risk and observed frequencies of adverse events, various framing effects, and contextualizing risk communication. We draw attention to some of the potential pitfalls in counseling about risk and offer avenues for circumventing them.

Should I Stay at Home or Should I Go Back to Work? Workforce Reentry Influences on a Mother's Decision-Making Process

ERIC Educational Resources Information Center

Ericksen, Kirsten S.; Jurgens, Jill C.; Garrett, Michael Tlanusta; Swedburg, Randy B.

2008-01-01

The authors examine the literature pertaining to women's life transitions and the difficult decision-making process some women encounter when reentering the workforce after a period of staying at home with young children. On the basis of the unique challenges faced by this population, the authors created a conceptual framework (i.e., the Mother's…

Believable Social and Emotional Agents.

DTIC Science & Technology

1996-05-01

While building tools to support the creation of believable emotional agents, I had to make a number of important design decisions . Before describing...processing systems, it is difficult to give an artist direct control over the emotion - al aspects of the character. By making these decisions explicit, I hope...Woody on “Cheers”). Believable Agents BELIEVABLE SOCIAL AND EMOTIONAL AGENTS 11 Lesson: We don’t want agent architectures that enforce rationality and

Titrating guidance: a model to guide physicians in assisting patients and family members who are facing complex decisions.

PubMed

Goldstein, Nathan E; Back, Anthony L; Morrison, R Sean

2008-09-08

Over the last century, developments in new medical treatments have led to an exponential increase in longevity, but, as a consequence, patients may be left with chronic illness associated with long-term severe functional and cognitive disability. Patients and their families are often forced to make a difficult and complex choice between death and long-term debility, neither of which is an acceptable outcome. Traditional models of medical decision making, however, do not fully address how clinicians should best assist with these decisions. Herein, we present a new paradigm that demonstrates how the role of the physician changes over time in response to the curved relationship between the predictability of a patient's outcome and the chance of returning to an acceptable quality of life. To translate this model into clinical practice, we propose a 5-step model for physicians with which they can (1) determine at which point the patient is on our model; (2) identify the cognitive factors and preferences for outcomes that affect the decision-making process of the patient and his or her family; (3) reflect on their own reaction to the decision at hand; (4) acknowledge how these factors can be addressed in conversation; and (5) guide the patient and his or her family in creating a plan of care. This model can help improve patient-physician communication and decision making so that complex and difficult decisions can be turned into ones that yield to medical expertise, good communication, and personal caring.

The patient's role in clinical decision-making.

PubMed

Brody, D S

1980-11-01

Practicing physicians must frequently make decisions about how much they wish to encourage patient participation in clinical decision-making and how to respond to rational patient demands that do not coincide with their own decisions. These are difficult ethical dilemmas with no indisputable or universal solutions. The traditional concept of the doctor-patient relationship places the patient in a passive, compliant role. The patient's only obligation is to seek competent help and cooperate with the physician. A number of factors have contributed to the continued dominance of the traditional doctor-patient imbalance of power. Despite these factors, there seems to be a great deal of public dissatisfaction with health care delivery in the United States; demands for more patient autonomy are increasing. This paper discusses the concept of mutual participation, presents an approach to encouraging patient participation in clinical decision-making, and considers its theoretical advantages.

Palliative Medicine and Decision Science: The Critical Need for a Shared Agenda To Foster Informed Patient Choice in Serious Illness

PubMed Central

Kryworuchko, Jennifer; Matlock, Dan D.; Volandes, Angelo E.

2011-01-01

Abstract Assisting patients and their families in complex decision making is a foundational skill in palliative care; however, palliative care clinicians and scientists have just begun to establish an evidence base for best practice in assisting patients and families in complex decision making. Decision scientists aim to understand and clarify the concepts and techniques of shared decision making (SDM), decision support, and informed patient choice in order to ensure that patient and family perspectives shape their health care experience. Patients with serious illness and their families are faced with myriad complex decisions over the course of illness and as death approaches. If patients lose capacity, then surrogate decision makers are cast into the decision-making role. The fields of palliative care and decision science have grown in parallel. There is much to be gained in advancing the practices of complex decision making in serious illness through increased collaboration. The purpose of this article is to use a case study to highlight the broad range of difficult decisions, issues, and opportunities imposed by a life-limiting illness in order to illustrate how collaboration and a joint research agenda between palliative care and decision science researchers, theorists, and clinicians might guide best practices for patients and their families. PMID:21895453

Simulation software: engineer processes before reengineering.

PubMed

Lepley, C J

2001-01-01

People make decisions all the time using intuition. But what happens when you are asked: "Are you sure your predictions are accurate? How much will a mistake cost? What are the risks associated with this change?" Once a new process is engineered, it is difficult to analyze what would have been different if other options had been chosen. Simulating a process can help senior clinical officers solve complex patient flow problems and avoid wasted efforts. Simulation software can give you the data you need to make decisions. The author introduces concepts, methodologies, and applications of computer aided simulation to illustrate their use in making decisions to improve workflow design.

Accounting for reasonableness: Exploring the personal internal framework affecting decisions about cancer drug funding.

PubMed

Sinclair, Shane; Hagen, Neil A; Chambers, Carole; Manns, Braden; Simon, Anita; Browman, George P

2008-05-01

Drug decision-makers are involved in developing and implementing policy, procedure and processes to support health resource allocation regarding drug treatment formularies. A variety of approaches to decision-making, including formal decision-making frameworks, have been developed to support transparent and fair priority setting. Recently, a decision tool, 'The 6-STEPPPs Tool', was developed to assist in making decisions about new cancer drugs within the public health care system. We conducted a qualitative study, utilizing focus groups and participant observation, in order to investigate the internal frameworks that supported and challenged individual participants as they applied this decision tool within a multi-stakeholder decision process. We discovered that health care resource allocation engaged not only the minds of decision-makers but profoundly called on the often conflicting values of the heart. Objective decision-making frameworks for new drug therapies need to consider the subjective internal frameworks of decision-makers that affect decisions. Understanding the very human, internal turmoil experienced by individuals involved in health care resource allocation, sheds additional insight into how to account for reasonableness and how to better support difficult decisions through transparent, values-based resource allocation policy, procedures and processes.

Ethical Decisions in Turbulent Times

ERIC Educational Resources Information Center

Shapiro, Joan Poliner; Gross, Steven Jay; Shapiro, Susan H.

2008-01-01

Education leaders make difficult ethical decisions each day. Using the story of a preschool director in lower Manhattan on September 11, 2001, the authors detail a series of paradigms to help educational leaders navigate rationally through challenging and complex circumstances when they are under considerable emotional stress. One approach which…

A new decision sciences for complex systems.

PubMed

Lempert, Robert J

2002-05-14

Models of complex systems can capture much useful information but can be difficult to apply to real-world decision-making because the type of information they contain is often inconsistent with that required for traditional decision analysis. New approaches, which use inductive reasoning over large ensembles of computational experiments, now make possible systematic comparison of alternative policy options using models of complex systems. This article describes Computer-Assisted Reasoning, an approach to decision-making under conditions of deep uncertainty that is ideally suited to applying complex systems to policy analysis. The article demonstrates the approach on the policy problem of global climate change, with a particular focus on the role of technology policies in a robust, adaptive strategy for greenhouse gas abatement.

Surviving Surrogate Decision-Making: What Helps and Hampers the Experience of Making Medical Decisions for Others

PubMed Central

Starks, Helene; Taylor, Janelle S.; Hopley, Elizabeth K.; Fryer-Edwards, Kelly

2007-01-01

BACKGROUND A majority of end-of-life medical decisions are made by surrogate decision-makers who have varying degrees of preparation and comfort with their role. Having a seriously ill family member is stressful for surrogates. Moreover, most clinicians have had little training in working effectively with surrogates. OBJECTIVES To better understand the challenges of decision-making from the surrogate’s perspective. DESIGN Semistructured telephone interview study of the experience of surrogate decision-making. PARTICIPANTS Fifty designated surrogates with previous decision-making experience. APPROACH We asked surrogates to describe and reflect on their experience of making medical decisions for others. After coding transcripts, we conducted a content analysis to identify and categorize factors that made decision-making more or less difficult for surrogates. RESULTS Surrogates identified four types of factors: (1) surrogate characteristics and life circumstances (such as coping strategies and competing responsibilities), (2) surrogates’ social networks (such as intrafamily discord about the “right” decision), (3) surrogate–patient relationships and communication (such as difficulties with honoring known preferences), and (4) surrogate–clinician communication and relationship (such as interacting with a single physician whom the surrogate recognizes as the clinical spokesperson vs. many clinicians). CONCLUSIONS These data provide insights into the challenges that surrogates encounter when making decisions for loved ones and indicate areas where clinicians could intervene to facilitate the process of surrogate decision-making. Clinicians may want to include surrogates in advance care planning prior to decision-making, identify and address surrogate stressors during decision-making, and designate one person to communicate information about the patient’s condition, prognosis, and treatment options. PMID:17619223

Complex Decision-Making in Heart Failure: A Systematic Review and Thematic Analysis.

PubMed

Hamel, Aimee V; Gaugler, Joseph E; Porta, Carolyn M; Hadidi, Niloufar Niakosari

Heart failure follows a highly variable and difficult course. Patients face complex decisions, including treatment with implantable cardiac defibrillators, mechanical circulatory support, and heart transplantation. The course of decision-making across multiple treatments is unclear yet integral to providing informed and shared decision-making. Recognizing commonalities across treatment decisions could help nurses and physicians to identify opportunities to introduce discussions and support shared decision-making. The specific aims of this review are to examine complex treatment decision-making, specifically implantable cardiac defibrillators, ventricular assist device, and cardiac transplantation, and to recognize commonalities and key points in the decisional process. MEDLINE, CINAHL, PsycINFO, and Web of Science were searched for English-language studies that included qualitative findings reflecting the complexity of heart failure decision-making. Using a 3-step process, findings were synthesized into themes and subthemes. Twelve articles met criteria for inclusion. Participants included patients, caregivers, and clinicians and included decisions to undergo and decline treatment. Emergent themes were "processing the decision," "timing and prognostication," and "considering the future." Subthemes described how participants received and understood information about the therapy, making and changing a treatment decision, timing their decision and gauging health status outcomes in the context of their decision, the influence of a life or death decision, and the future as a factor in their decisional process. Commonalities were present across therapies, which involved the timing of discussions, the delivery of information, and considerations of the future. Exploring this further could help support patient-centered care and optimize shared decision-making interventions.

Clinical assessment of decision-making capacity in acquired brain injury with personality change.

PubMed

Owen, Gareth S; Freyenhagen, Fabian; Martin, Wayne; David, Anthony S

2017-01-01

Assessment of decision-making capacity (DMC) can be difficult in acquired brain injury (ABI) particularly with the syndrome of organic personality disorder (OPD) (the "frontal lobe syndrome"). Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of deficit and thinking about psychological states can be present. However, the awareness of deficit may not be "online" and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: (1) necessary for DMC, (2) threatened by ABI , and (3) assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined.

The Importance Of Integrating Narrative Into Health Care Decision Making.

PubMed

Dohan, Daniel; Garrett, Sarah B; Rendle, Katharine A; Halley, Meghan; Abramson, Corey

2016-04-01

When making health care decisions, patients and consumers use data but also gather stories from family and friends. When advising patients, clinicians consult the medical evidence but also use professional judgment. These stories and judgments, as well as other forms of narrative, shape decision making but remain poorly understood. Furthermore, qualitative research methods to examine narrative are rarely included in health science research. We illustrate how narratives shape decision making and explain why it is difficult but necessary to integrate qualitative research on narrative into the health sciences. We draw on social-scientific insights on rigorous qualitative research and our ongoing studies of decision making by patients with cancer, and we describe new tools and approaches that link qualitative research findings with the predominantly quantitative health science scholarship. Finally, we highlight the benefits of more fully integrating qualitative research and narrative analysis into the medical evidence base and into evidence-based medical practice. Project HOPE—The People-to-People Health Foundation, Inc.

The use of Ethics Decision-Making Frameworks by Canadian Ethics Consultants: A Qualitative Study.

PubMed

Kaposy, Chris; Brunger, Fern; Maddalena, Victor; Singleton, Richard

2016-10-01

In this study, Canadian healthcare ethics consultants describe their use of ethics decision-making frameworks. Our research finds that ethics consultants in Canada use multi-purpose ethics decision-making frameworks, as well as targeted frameworks that focus on reaching an ethical resolution to a particular healthcare issue, such as adverse event reporting, or difficult triage scenarios. Several interviewees mention the influence that the accreditation process in Canadian healthcare organizations has on the adoption and use of such frameworks. Some of the ethics consultants we interviewed also report on their reluctance to use these tools. Limited empirical work has been done previously on the use of ethics decision-making frameworks. This study begins to fill this gap in our understanding of the work of healthcare ethics consultants. © 2016 John Wiley & Sons Ltd.

The evaluation of lifestyle interventions in the Netherlands.

PubMed

Rappange, David R; Brouwer, Werner B F

2012-04-01

Current investments in preventive lifestyle interventions are relatively low, despite the significant impact of unhealthy behaviour on population health. This raises the question of whether the criteria used in reimbursement decisions about healthcare interventions put preventive interventions at a disadvantage. In this paper, we highlight the decision-making framework used in the Netherlands to delineate the basic benefits package. Important criteria in that framework are 'necessity' and 'cost-effectiveness'. Several normative choices need to be made, and these choices can have an important impact on the evaluation of lifestyle interventions, especially when making these criteria operational and quantifiable. Moreover, the implementation of the decision-making framework may prove to be difficult for lifestyle interventions. Improvements of the decision-making framework in the Netherlands are required to guarantee sound evaluations of lifestyle interventions aimed at improving health.

Fuzzy indicator approach: development of impact factor of soil amendments

USDA-ARS?s Scientific Manuscript database

Soil amendments have been shown to be useful for improving soil condition, but it is often difficult to make management decisions as to their usefulness. Utilization of Fuzzy Set Theory is a promising method for decision support associated with utilization of soil amendments. In this article a tool ...

Bringing Reality to "Real Options": An Experiential Exercise

ERIC Educational Resources Information Center

Turner, Craig; Turner, Kyle Dean

2015-01-01

Issues surrounding the contextual environment in which strategic decisions are made are difficult concepts to grasp, particularly for undergraduate students with little business experience. They are also problematic for graduate students that have not been called on to make such decisions within their career. The authors propose an exercise that…

Accreditation, ROI, and the Online Academic Library

ERIC Educational Resources Information Center

Stielow, Fred

2011-01-01

Today's academic libraries must demonstrate their value to cost-conscious university administrators. Budget trade-off decisions that involve the library can be difficult for any university administrator to make, and such decisions are complicated by the recent appearance of massive global digital libraries that seem poised to replace the…

Eating and drinking interventions for people at risk of lacking decision-making capacity: who decides and how?

PubMed

Clarke, Gemma; Galbraith, Sarah; Woodward, Jeremy; Holland, Anthony; Barclay, Stephen

2015-06-11

Some people with progressive neurological diseases find they need additional support with eating and drinking at mealtimes, and may require artificial nutrition and hydration. Decisions concerning artificial nutrition and hydration at the end of life are ethically complex, particularly if the individual lacks decision-making capacity. Decisions may concern issues of life and death: weighing the potential for increasing morbidity and prolonging suffering, with potentially shortening life. When individuals lack decision-making capacity, the standard processes of obtaining informed consent for medical interventions are disrupted. Increasingly multi-professional groups are being utilised to make difficult ethical decisions within healthcare. This paper reports upon a service evaluation which examined decision-making within a UK hospital Feeding Issues Multi-Professional Team. A three month observation of a hospital-based multi-professional team concerning feeding issues, and a one year examination of their records. The key research questions are: a) How are decisions made concerning artificial nutrition for individuals at risk of lacking decision-making capacity? b) What are the key decision-making factors that are balanced? c) Who is involved in the decision-making process? Decision-making was not a singular decision, but rather involved many different steps. Discussions involving relatives and other clinicians, often took place outside of meetings. Topics of discussion varied but the outcome relied upon balancing the information along four interdependent axes: (1) Risks, burdens and benefits; (2) Treatment goals; (3) Normative ethical values; (4) Interested parties. Decision-making was a dynamic ongoing process with many people involved. The multiple points of decision-making, and the number of people involved with the decision-making process, mean the question of 'who decides' cannot be fully answered. There is a potential for anonymity of multiple decision-makers to arise. Decisions in real world clinical practice may not fit precisely into a model of decision-making. The findings from this service evaluation illustrate that within multi-professional team decision-making; decisions may contain elements of both substituted and supported decision-making, and may be better represented as existing upon a continuum.

Patient experiences of acute myeloid leukemia: A qualitative study about diagnosis, illness understanding, and treatment decision-making.

PubMed

LeBlanc, Thomas W; Fish, Laura J; Bloom, Catherine T; El-Jawahri, Areej; Davis, Debra M; Locke, Susan C; Steinhauser, Karen E; Pollak, Kathryn I

2017-12-01

Patients with acute myeloid leukemia (AML) face a unique, difficult situation characterized by sudden changes in health, complex information, and pressure to make quick treatment decisions amid sizeable tradeoffs. Yet, little is known about patients' experiences with AML. We used qualitative methods to learn about their experiences with diagnosis and treatment decision-making to identify areas for improvement. We recruited hospitalized patients with AML to participate in semi-structured qualitative interviews about their experiences being diagnosed with AML, receiving information, and making a treatment decision. Interviews were conducted during their hospitalization for induction chemotherapy. We analyzed data by using a constant comparison approach. Thirty-two patients completed an interview. Four main themes emerged: (a) shock and suddenness, (b) difficulty processing information, (c) poor communication, and (d) uncertainty. Patients frequently described their diagnosis as shocking. They also felt that the amount of information was too great and too difficult to process, which negatively impacted their understanding. Patients frequently described a lack of emotional support from clinicians and described uncertainty about their prognosis, the number and nature of available treatments, and what to expect from treatment. Acute myeloid leukemia poses a sudden, emotionally challenging, information-laden situation, where little time is available to make important decisions. This results in difficulty processing information and is sometimes complicated by a lack of emotive communication from clinicians. Results indicate a need for targeted interventions to improve AML patients' understanding of illness and treatment options and to address their traumatic experiences around diagnosis. Copyright © 2016 John Wiley & Sons, Ltd.

Moving toward comprehensive acute heart failure risk assessment in the emergency department: the importance of self-care and shared decision making.

PubMed

Collins, Sean P; Storrow, Alan B

2013-08-01

Nearly 700,000 emergency department (ED) visits were due to acute heart failure (AHF) in 2009. Most visits result in a hospital admission and account for the largest proportion of a projected $70 billion to be spent on heart failure care by 2030. ED-based risk prediction tools in AHF rarely impact disposition decision making. This is a major factor contributing to the 80% admission rate for ED patients with AHF, which has remained unchanged over the last several years. Self-care behaviors such as symptom monitoring, medication taking, dietary adherence, and exercise have been associated with decreased hospital readmissions, yet self-care remains largely unaddressed in ED patients with AHF and thus represents a significant lost opportunity to improve patient care and decrease ED visits and hospitalizations. Furthermore, shared decision making encourages collaborative interaction between patients, caregivers, and providers to drive a care path based on mutual agreement. The observation that “difficult decisions now will simplify difficult decisions later” has particular relevance to the ED, given this is the venue for many such issues. We hypothesize patients as complex and heterogeneous as ED patients with AHF may need both an objective evaluation of physiologic risk as well as an evaluation of barriers to ideal self-care, along with strategies to overcome these barriers. Combining physician gestalt, physiologic risk prediction instruments, an evaluation of self-care, and an information exchange between patient and provider using shared decision making may provide the critical inertia necessary to discharge patients home after a brief ED evaluation.

[Who makes decisions--the dilemma of decision-making within the framework of job-sharing in a hospital].

PubMed

Voglmayr, Elisabeth; Widder, Joachim

2006-05-01

By means of a case report on a 44-year-old female patient, we show how, with changing personnel and places of care, decisions as well as the kind of decision-making during illness influence the quality of care. The patient was receiving immunosuppressive therapy after kidney transplantation and then suffered from a carcinomatous ovary. At first she refused postoperative chemotherapy, but then returned with a very advanced state of metastatic growth. The lack of continuity, a missing overall interdisciplinary concept of medical case, as well as the failure to document decision processes and the patient's attitude to life and suffering made it difficult for the caring team to accompany her in the last weeks of life. A possible solution to such a complex problem will be the introduction of ethical case deliberation.

Difficult decisions: Migration from Small Island Developing States under climate change

NASA Astrophysics Data System (ADS)

Kelman, Ilan

2015-04-01

The impacts of climate change on Small Island Developing States (SIDS) are leading to discussions regarding decision-making about the potential need to migrate. Despite the situation being well-documented, with many SIDS aiming to raise the topic to prominence and to take action for themselves, limited support and interest has been forthcoming from external sources. This paper presents, analyzes, and critiques a decision-making flowchart to support actions for SIDS dealing with climate change-linked migration. The flowchart contributes to identifying the pertinent topics to consider and the potential support needed to implement decision-making. The flowchart has significant limitations and there are topics which it cannot resolve. On-the-ground considerations include who decides, finances, implements, monitors, and enforces each decision. Additionally, views within communities differ, hence mechanisms are needed for dealing with differences, while issues to address include moral and legal blame for any climate change-linked migration, the ultimate goal of the decision-making process, the wider role of migration in SIDS communities and the right to judge decision-making and decisions. The conclusions summarize the paper, emphasizing the importance of considering contexts beyond climate change and multiple SIDS voices.

Applying Safety Treatments to Rail-Highway At-grade Crossings

DOT National Transportation Integrated Search

2012-05-23

The best solution to rail crossing crashes is to remove the need for the driver to engage in a potentially faulty decision-making process by : making it impossible, or at least very difficult, for the driver to bypass lowered gates. Two methods, medi...

Decision-making impairments in the context of intact reward sensitivity in schizophrenia.

PubMed

Heerey, Erin A; Bell-Warren, Kimberly R; Gold, James M

2008-07-01

Deficits in motivated behavior and decision-making figure prominently in the behavioral syndrome that characterizes schizophrenia and are difficult both to treat and to understand. One explanation for these deficits is that schizophrenia decreases sensitivity to rewards in the environment. An alternate explanation is that sensitivity to rewards is intact but that poor integration of affective with cognitive information impairs the ability to use this information to guide behavior. We tested reward sensitivity with a modified version of an existing signal detection task with asymmetric reinforcement and decision-making with a probabilistic decision-making task in 40 participants with schizophrenia and 26 healthy participants. Results showed normal sensitivity to reward in participants with schizophrenia but differences in choice patterns on the decision-making task. A logistic regression model of the decision-making data showed that participants with schizophrenia differed from healthy participants in the ability to weigh potential outcomes, specifically potential losses, when choosing between competing response options. Deficits in working memory ability accounted for group differences in ability to use potential outcomes during decision-making. These results suggest that the implicit mechanisms that drive reward-based learning are surprisingly intact in schizophrenia but that poor ability to integrate cognitive and affective information when calculating the value of possible choices might hamper the ability to use such information during explicit decision-making.

[Involving patients, the insured and the general public in healthcare decision making].

PubMed

Mühlbacher, Axel C; Juhnke, Christin

2016-01-01

No doubt, the public should be involved in healthcare decision making, especially when decision makers from politics and self-government agencies are faced with the difficult task of setting priorities. There is a general consensus on the need for a stronger patient centeredness, even in HTA processes, and internationally different ways of public participation are discussed and tested in decision making processes. This paper describes how the public can be involved in different decision situations, and it shows how preference measurement methods are currently being used in an international context to support decision making. It distinguishes between different levels of decision making on health technologies: approval, assessment, pricing, and finally utilization. The range of participation efforts extends from qualitative surveys of patients' needs (Citizen Councils of NICE in the UK) to science-based documentation of quantitative patient preferences, such as in the current pilot projects of the FDA in the US and the EMA at the European level. Possible approaches for the elicitation and documentation of preference structures and trade-offs in relation to alternate health technologies are decision aids, such as multi-criteria decision analysis (MCDA), that provide the necessary information for weighting and prioritizing decision criteria. Copyright © 2015. Published by Elsevier GmbH.

Reduction of influence of task difficulty on perceptual decision making by STN deep brain stimulation.

PubMed

Green, Nikos; Bogacz, Rafal; Huebl, Julius; Beyer, Ann-Kristin; Kühn, Andrea A; Heekeren, Hauke R

2013-09-09

Neurocomputational models of optimal decision making ascribe a crucial role-the computation of conflict between choice alternatives-to the subthalamic nucleus (STN). Specifically, these models predict that deep brain stimulation (DBS) of the STN will diminish the influence of decision conflict on decision making. In this work, patients with Parkinson's disease judged the direction of motion in random dot stimuli while ON and OFF DBS. To induce decision conflict, we varied the task difficulty (motion coherence), leading to increased reaction time (RT) in trials with greater task difficulty in healthy subjects. Results indicate that DBS significantly influences performance for perceptual decisions under high decision conflict. RT increased substantially OFF DBS as the task became more difficult, and a diffusion model best accounted for behavioral data. In contrast, ON DBS, the influence of task difficulty on RT was significantly reduced and a race model best accounted for the observed data. Individual data fits of evidence accumulation models demonstrate different information processing under distinct DBS states. Furthermore, ON DBS, speed-accuracy tradeoffs affected the magnitude of decision criterion adjustment significantly less compared to OFF DBS. Together, these findings suggest a crucial role for the STN in adjusting decision making during high-conflict trials in perceptual decision making. Copyright © 2013 Elsevier Ltd. All rights reserved.

Decision theory and the evaluation of risks and benefits of clinical trials.

PubMed

Bernabe, Rosemarie D C; van Thiel, Ghislaine J M W; Raaijmakers, Jan A M; van Delden, Johannes J M

2012-12-01

Research ethics committees (RECs) are tasked to assess the risks and the benefits of a clinical trial. In previous studies, it was shown that RECs find this task difficult, if not impossible, to do. The current approaches to benefit-risk assessment (i.e. Component Analysis and the Net Risk Test) confound the various risk-benefit tasks, and as such, make balancing impossible. In this article, we show that decision theory, specifically through the expected utility theory and multiattribute utility theory, enable for an explicit and ethically weighted risk-benefit evaluation. This makes a balanced ethical justification possible, and thus a more rationally defensible decision making. Copyright © 2012 Elsevier Ltd. All rights reserved.

Neural reactivation links unconscious thought to decision-making performance.

PubMed

Creswell, John David; Bursley, James K; Satpute, Ajay B

2013-12-01

Brief periods of unconscious thought (UT) have been shown to improve decision making compared with making an immediate decision (ID). We reveal a neural mechanism for UT in decision making using blood oxygen level-dependent (BOLD) functional magnetic resonance imaging. Participants (N = 33) encoded information on a set of consumer products (e.g. 48 attributes describing four different cars), and we manipulated whether participants (i) consciously thought about this information (conscious thought), (ii) completed a difficult 2-back working memory task (UT) or (iii) made an immediate decision about the consumer products (ID) in a within-subjects blocked design. To differentiate UT neural activity from 2-back working memory neural activity, participants completed an independent 2-back task and this neural activity was subtracted from neural activity occurring during the UT 2-back task. Consistent with a neural reactivation account, we found that the same regions activated during the encoding of complex decision information (right dorsolateral prefrontal cortex and left intermediate visual cortex) continued to be activated during a subsequent 2-min UT period. Moreover, neural reactivation in these regions was predictive of subsequent behavioral decision-making performance after the UT period. These results provide initial evidence for post-encoding unconscious neural reactivation in facilitating decision making.

Neural reactivation links unconscious thought to decision-making performance

PubMed Central

Bursley, James K.; Satpute, Ajay B.

2013-01-01

Brief periods of unconscious thought (UT) have been shown to improve decision making compared with making an immediate decision (ID). We reveal a neural mechanism for UT in decision making using blood oxygen level-dependent (BOLD) functional magnetic resonance imaging. Participants (N = 33) encoded information on a set of consumer products (e.g. 48 attributes describing four different cars), and we manipulated whether participants (i) consciously thought about this information (conscious thought), (ii) completed a difficult 2-back working memory task (UT) or (iii) made an immediate decision about the consumer products (ID) in a within-subjects blocked design. To differentiate UT neural activity from 2-back working memory neural activity, participants completed an independent 2-back task and this neural activity was subtracted from neural activity occurring during the UT 2-back task. Consistent with a neural reactivation account, we found that the same regions activated during the encoding of complex decision information (right dorsolateral prefrontal cortex and left intermediate visual cortex) continued to be activated during a subsequent 2-min UT period. Moreover, neural reactivation in these regions was predictive of subsequent behavioral decision-making performance after the UT period. These results provide initial evidence for post-encoding unconscious neural reactivation in facilitating decision making. PMID:23314012

Long-term integrating samplers for indoor air and sub slab soil gas at VI sites

EPA Science Inventory

Vapor intrusion (VI) site assessments are plagued by substantial spatial and temporal variability that makes exposure and risk assessment difficult. Most risk-based decision making for volatile organic compound (VOC) exposure in the indoor environment is based on health benchmark...

The spirits of capitalism and christianity and their impact on the formation of healthcare leaders.

PubMed

LaMothe, Ryan

2013-03-01

In this article, I portray how the ethos of Christianity, broadly speaking, and the mores of capitalism intersect in the formation of healthcare leaders and the difficult decisions they make in insuring the viability of healthcare institutions. More particularly, I argue that healthcare leaders in Christian healthcare institutions are largely formed by and dependent on a capitalistic ethos in making decisions and less so by a Christian ethos. There are key differences in these two meaning systems, and these differences, in part, reveal an incompatibility between them. This incompatibility does not imply a rejection of capitalism, if that is even possible, but rather a recognition of its effects and limits vis-à-vis the formation of healthcare leaders and their decision-making process. Finally, I offer an approach that deals with the spirits of capitalism and Christianity in forming healthcare leaders and their decision-making.

Variability in visual working memory ability limits the efficiency of perceptual decision making.

PubMed

Ester, Edward F; Ho, Tiffany C; Brown, Scott D; Serences, John T

2014-04-02

The ability to make rapid and accurate decisions based on limited sensory information is a critical component of visual cognition. Available evidence suggests that simple perceptual discriminations are based on the accumulation and integration of sensory evidence over time. However, the memory system(s) mediating this accumulation are unclear. One candidate system is working memory (WM), which enables the temporary maintenance of information in a readily accessible state. Here, we show that individual variability in WM capacity is strongly correlated with the speed of evidence accumulation in speeded two-alternative forced choice tasks. This relationship generalized across different decision-making tasks, and could not be easily explained by variability in general arousal or vigilance. Moreover, we show that performing a difficult discrimination task while maintaining a concurrent memory load has a deleterious effect on the latter, suggesting that WM storage and decision making are directly linked.

Choosing Child Care: Birth to Three

ERIC Educational Resources Information Center

Child Care, Inc., 2012

2012-01-01

Like all difficult decisions, choosing child care can seem overwhelming, and this is particularly true when choosing care for children under three. The better you understand what your child's and your own personal needs are, and what is available and affordable to you, the more confident you will become in your decision-making process. This…

Family Health and Financial Literacy--Forging the Connection

ERIC Educational Resources Information Center

Braun, Bonnie; Kim, Jinhee; Anderson, Elaine A.

2009-01-01

Families are at-risk of or experiencing a diminished quality of living and life in current economic times and difficult decisions are required. Health and financial literacy are the basis for wise personal and public decision making. Family and consumer sciences (FCS) professionals can forge connections between health and financial literacy to…

Season ending events, a matter of perspective

Treesearch

Laurie L. Kurth

2010-01-01

Agency managers are often faced with making difficult wildland fire management decisions based on collating a significant amount of information regarding a fire. Supporting the decisions is understanding how long an incident may persist, especially if the fire has potential for resource benefits. Analysis of historical season ending events has occurred since the mid-...

Decision-Making under Stress: World War II and Beyond.

ERIC Educational Resources Information Center

Johns, Robert

1986-01-01

Provides a teaching plan which helps students imaginatively take the roles of leaders in the United States during World War II so that they might more completely understand such difficult decisions as allying with the Soviet Union, relocating Japanese-Americans, and dropping the atomic bomb. Provides a statement of goals and objectives, required…

Families as Decision-Makers: When Researchers and Advocates Work Together

ERIC Educational Resources Information Center

Fields-Smith, Cheryl; Neuharth-Pritchett, Stacey

2009-01-01

Families across the United States must routinely make difficult choices about child care arrangements because of the need to resume a job, continue an education or training program, or care for other family members. Leaving children in the care of others for the first time can be difficult (Sayer, Bianchi, & Robinson, 2004; Van Horn, Ramey,…

Consequences Identification in Forecasting and Ethical Decision-making

PubMed Central

Stenmark, Cheryl K.; Antes, Alison L.; Thiel, Chase E.; Caughron, Jared J.; Wang, Xiaoqian; Mumford, Michael D.

2015-01-01

Forecasting involves predicting outcomes based on observations of the situation at hand. We examined the impact of the number and types of consequences considered on the quality of ethical decision-making. Undergraduates role-played several ethical problems in which they forecast potential outcomes and made decisions. Performance pressure (difficult demands placed on the situation) and interpersonal conflict (clashes among people in the problem situation) were manipulated within each problem scenario. The results indicated that the identification of potential consequences was positively associated with both higher quality forecasts and more ethical decisions. Neither performance pressure nor interpersonal conflict affected the quality of forecasts or decisions. Theoretical and practical implications of these findings and the use of this research approach are discussed. PMID:21460584

Front-Line Physicians' Satisfaction with Information Systems in Hospitals.

PubMed

Peltonen, Laura-Maria; Junttila, Kristiina; Salanterä, Sanna

2018-01-01

Day-to-day operations management in hospital units is difficult due to continuously varying situations, several actors involved and a vast number of information systems in use. The aim of this study was to describe front-line physicians' satisfaction with existing information systems needed to support the day-to-day operations management in hospitals. A cross-sectional survey was used and data chosen with stratified random sampling were collected in nine hospitals. Data were analyzed with descriptive and inferential statistical methods. The response rate was 65 % (n = 111). The physicians reported that information systems support their decision making to some extent, but they do not improve access to information nor are they tailored for physicians. The respondents also reported that they need to use several information systems to support decision making and that they would prefer one information system to access important information. Improved information access would better support physicians' decision making and has the potential to improve the quality of decisions and speed up the decision making process.

[Adoption of new technologies by health services: the challenge of analyzing relevant factors].

PubMed

Trindade, Evelinda

2008-05-01

The exponential increase in the incorporation of health technologies has been considered a key factor in increased expenditures by the health sector. Such decisions involve multiple levels and stakeholders. Decentralization has multiplied the decision-making levels, with numerous difficult choices and limited resources. The interrelationship between stakeholders is complex, in creative systems with multiple determinants and confounders. The current review discusses the interaction between the factors influencing the decisions to incorporate technologies by health services, and proposes a structure for their analysis. The application and intensity of these factors in decision-making and the incorporation of products and programs by health services shapes the installed capacity of local and regional networks and modifies the health system. Empirical observation of decision-making and technology incorporation in Brazilian health services poses an important challenge. The structured recognition and measurement of these variables can assist proactive planning of health services.

Using health outcomes data to inform decision-making: formulary committee perspective.

PubMed

Janknegt, R

2001-01-01

When healthcare resources are limited, decisions about the treatments to fund can be complex and difficult to make, involving the careful balancing of multiple factors. The decisions taken may have far-reaching consequences affecting many people. Clearly, decisions such as the choice of products on a formulary must be taken using a selection process that is fully transparent and that can be justified to all parties concerned. Although everyone would agree that drug selection should be a rational process that follows the guidelines of evidence-based medicine, many other factors may play a role in decision-making. Although some of these are explicit and rational, others are less clearly defined, and decision-makers may be unaware of the influence exerted by some of these factors. In order to facilitate transparent decision-making that makes rational use of health outcomes information, the System of Objectified Judgement Analysis (SOJA) has been developed by the author. SOJA includes interactive software that combines the quality advantages of the 'top-down' approach to drug selection, based on a thorough literature review, with the compliance advantages of a 'bottom-up' approach, where the final decision is made by the individual formulary committee and not by the authors of the review. The SOJA method, based on decision-making processes in economics, ensures that health outcomes information is given appropriate weight. Such approaches are valuable tools in discussions about product selection for formularies.

Personal finance: there are no shortcuts to financial security.

PubMed

Yarkony, Kathryn

2009-12-01

Perioperative nurses have skills that lend themselves to sound financial decision-making, and during these difficult economic times, it is important to know how to secure earnings for the future. Key strategies include saving for retirement, consulting a financial advisor, investing in reliable vehicles, holding investments until the market stabilizes, and controlling credit card debt. Nurses can use the nursing process of assessment, diagnosis, planning, implementation, and evaluation to help them make sound financial decisions. (c) AORN, Inc, 2009.

Seasonal weather-related decision making for cattle production in the Northern Great Plains

USDA-ARS?s Scientific Manuscript database

High inter-annual variability of seasonal weather patterns can greatly affect forage and therefore livestock production in the Northern Great Plains. This variability can make it difficult for ranchers to set yearly stocking rates, particularly in advance of the grazing season. To better understand ...

How modifiable factors influence parental decision-making about organ donation.

PubMed

Luberda, Kamila; Cleaver, Karen

2017-11-07

A global shortage of organs from children and adults available for transplantation is compounded by the failure of next of kin to consent for organs to be donated after death. Non-modifiable and modifiable factors influence decision-making in this area. Modifiable factors are of interest when examining families' decision-making about the donation of organs from their deceased child. A scoping review was undertaken to determine how modifiable factors influence parental decision-making about organ donation. Thematic analysis identified two themes: interactions with healthcare professionals and pre-disposition to organ donation. Satisfaction with experiences of hospital care, the information provided and the way it was communicated, as well as interactions pertaining to emotional support were all found to be modifiable factors that influenced decision making. Likewise, a predisposition to organ donation and knowing the deceased's wishes were associated with the consent decision. Nurses working in critical care environments need to be able to support parents during this difficult time. This article aims to raise awareness of modifiable factors that influence parental decision-making, highlighting their relevance for children's nursing practice. ©2017 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

To pass or to fail? Understanding the factors considered by faculty in the clinical evaluation of nursing students.

PubMed

DeBrew, Jacqueline Kayler; Lewallen, Lynne Porter

2014-04-01

Making the decision to pass or to fail a nursing student is difficult for nurse educators, yet one that all educators face at some point in time. To make this decision, nurse educators draw from their past experiences and personal reflections on the situation. Using the qualitative method of critical incident technique, the authors asked educators to describe a time when they had to make a decision about whether to pass or fail a student in the clinical setting. The findings describe student and faculty factors important in clinical evaluation decisions, demonstrate the benefits of reflective practice to nurse educators, and support the utility of critical incident technique not only as research methodology, but also as a technique for reflective practice. Copyright © 2013 Elsevier Ltd. All rights reserved.

Prioritization of Stockpile Maintenance with Layered Pareto Fronts

DOE Office of Scientific and Technical Information (OSTI.GOV)

Burke, Sarah E.; Anderson-Cook, Christine M.; Lu, Lu

Difficult choices are required for a decision-making process where resources and budgets are increasingly constrained. This study demonstrates a structured decision-making approach using layered Pareto fronts to identify priorities about how to allocate funds between munitions stockpiles based on their estimated reliability, the urgency of needing available units, and the consequences if adequate numbers of units are not available. This case study, while specific to the characteristics of a group of munitions stockpiles, illustrates the general process of structured decision-making based on first identifying appropriate metrics that summarize the important dimensions of the decision, and then objectively eliminating non-contenders frommore » further consideration. Finally, the final subjective stage incorporates user priorities to select the four stockpiles to receive additional maintenance and surveillance funds based on understanding the trade-offs and robustness to various user priorities.« less

Prioritization of Stockpile Maintenance with Layered Pareto Fronts

DOE PAGES

Burke, Sarah E.; Anderson-Cook, Christine M.; Lu, Lu; ...

2017-10-11

Difficult choices are required for a decision-making process where resources and budgets are increasingly constrained. This study demonstrates a structured decision-making approach using layered Pareto fronts to identify priorities about how to allocate funds between munitions stockpiles based on their estimated reliability, the urgency of needing available units, and the consequences if adequate numbers of units are not available. This case study, while specific to the characteristics of a group of munitions stockpiles, illustrates the general process of structured decision-making based on first identifying appropriate metrics that summarize the important dimensions of the decision, and then objectively eliminating non-contenders frommore » further consideration. Finally, the final subjective stage incorporates user priorities to select the four stockpiles to receive additional maintenance and surveillance funds based on understanding the trade-offs and robustness to various user priorities.« less

The conceptualisation of health-related quality of life in decision-making by intensive care physicians: A qualitative inquiry.

PubMed

Haines, Dr Kimberley J; Remedios, Louisa; Berney, Sue C; Knott, Dr Cameron; Denehy, Linda

2017-05-01

To explore how intensive care physicians conceptualise and prioritise patient health-related quality of life in their decision-making. General qualitative inquiry using elements of Grounded Theory. Six ICU physicians participated. A large, closed, mixed ICU at a university-affiliated hospital, Australia. Three themes emerged: (1) Multi-dimensionality of HRQoL-HRQoL was described as difficult to understand; the patient was viewed as the best informant. Proxy information on HRQoL and health preferences was used to direct clinical care, despite not always being trusted. (2) Prioritisation of HRQoL within decision-making-this varied across the patient's health care trajectory. Premorbid HRQoL was prioritised when making admission decisions and used to predict future HRQoL. (3) Role of physician in decision-making-the physicians described their role as representing society with peers influencing their decision-making. All participants considered their practice to be similar to their peers, referring to their practice as the "middle of the road". This is a novel finding, emphasising other important influences in high-stakes decision-making. Critical care physicians conceptualised HRQoL as a multi-dimensional subjective construct. Patient (or proxy) voice was integral in establishing patient HRQoL and future health preferences. HRQoL was important in high stakes decision-making including initiating invasive and burdensome therapies or in redirecting therapeutic goals. Copyright © 2016 Australian College of Critical Care Nurses Ltd. All rights reserved.

A systematic review of online resources to support patient decision-making for full-thickness rectal prolapse surgery.

PubMed

Fowler, G E; Baker, D M; Lee, M J; Brown, S R

2017-11-01

The internet is becoming an increasingly popular resource to support patient decision-making outside of the clinical encounter. The quality of online health information is variable and largely unregulated. The aim of this study was to assess the quality of online resources to support patient decision-making for full-thickness rectal prolapse surgery. This systematic review was registered on the PROSPERO database (CRD42017058319). Searches were performed on Google and specialist decision aid repositories using a pre-defined search strategy. Sources were analysed according to three measures: (1) their readability using the Flesch-Kincaid Reading Ease score, (2) DISCERN score and (3) International Patient Decision Aids Standards (IPDAS) minimum standards criteria score (IPDASi, v4.0). Overall, 95 sources were from Google and the specialist decision aid repositories. There were 53 duplicates removed, and 18 sources did not meet the pre-defined eligibility criteria, leaving 24 sources included in the full-text analysis. The mean Flesch-Kincaid Reading Ease score was higher than recommended for patient education materials (48.8 ± 15.6, range 25.2-85.3). Overall quality of sources supporting patient decision-making for full-thickness rectal prolapse surgery was poor (median DISCERN score 1/5 ± 1.18, range 1-5). No sources met minimum decision-making standards (median IPDASi score 5/12 ± 2.01, range 1-8). Currently, easily accessible online health information to support patient decision-making for rectal surgery is of poor quality, difficult to read and does not support shared decision-making. It is recommended that professional bodies and medical professionals seek to develop decision aids to support decision-making for full-thickness rectal prolapse surgery.

Situating methodology within qualitative research.

PubMed

Kramer-Kile, Marnie L

2012-01-01

Qualitative nurse researchers are required to make deliberate and sometimes complex methodological decisions about their work. Methodology in qualitative research is a comprehensive approach in which theory (ideas) and method (doing) are brought into close alignment. It can be difficult, at times, to understand the concept of methodology. The purpose of this research column is to: (1) define qualitative methodology; (2) illuminate the relationship between epistemology, ontology and methodology; (3) explicate the connection between theory and method in qualitative research design; and 4) highlight relevant examples of methodological decisions made within cardiovascular nursing research. Although there is no "one set way" to do qualitative research, all qualitative researchers should account for the choices they make throughout the research process and articulate their methodological decision-making along the way.

Classification images reveal decision variables and strategies in forced choice tasks

PubMed Central

Pritchett, Lisa M.; Murray, Richard F.

2015-01-01

Despite decades of research, there is still uncertainty about how people make simple decisions about perceptual stimuli. Most theories assume that perceptual decisions are based on decision variables, which are internal variables that encode task-relevant information. However, decision variables are usually considered to be theoretical constructs that cannot be measured directly, and this often makes it difficult to test theories of perceptual decision making. Here we show how to measure decision variables on individual trials, and we use these measurements to test theories of perceptual decision making more directly than has previously been possible. We measure classification images, which are estimates of templates that observers use to extract information from stimuli. We then calculate the dot product of these classification images with the stimuli to estimate observers' decision variables. Finally, we reconstruct each observer's “decision space,” a map that shows the probability of the observer’s responses for all values of the decision variables. We use this method to examine decision strategies in two-alternative forced choice (2AFC) tasks, for which there are several competing models. In one experiment, the resulting decision spaces support the difference model, a classic theory of 2AFC decisions. In a second experiment, we find unexpected decision spaces that are not predicted by standard models of 2AFC decisions, and that suggest intrinsic uncertainty or soft thresholding. These experiments give new evidence regarding observers’ strategies in 2AFC tasks, and they show how measuring decision variables can answer long-standing questions about perceptual decision making. PMID:26015584

Teaching versus Living: Managerial Decision Making in the Gray

ERIC Educational Resources Information Center

Soltes, Eugene

2017-01-01

Preparing students for the consequential ethical decisions that they will face in their careers is among the most difficult tasks of management education. I describe some of these challenges based on my book "Why They Do It: Inside the Mind of the White-Collar Criminal" and recent work in behavioral ethics. I explore why some decisions…

Managing in a Culture of Debate: Enhancing Administrative Effectiveness through Procedural Fairness

ERIC Educational Resources Information Center

Moshavi, Dan; Standifird, Stephen

2017-01-01

The contestability of ideas is at the heart of a healthy academic institution. As a result, administrators face the challenge of making and implementing difficult decisions in an environment that is designed to explicitly create thoughtful discord. We argue that procedural fairness--explaining how and why important decisions are made--is an…

Purchasing a Used Car Using Multiple Criteria Decision Making

ERIC Educational Resources Information Center

Edwards, Thomas G.; Chelst, Kenneth R.

2007-01-01

When studying mathematics, students often ask the age-old question, "When will I ever use this in my future?" The activities described in this article demonstrate for students a process that brings the power of mathematical reasoning to bear on a difficult decision involving multiple criteria that is sure to resonate with the interests of many of…

Factors influencing parental decision making about stimulant treatment for attention-deficit/hyperactivity disorder.

PubMed

Ahmed, Rana; McCaffery, Kirsten J; Aslani, Parisa

2013-04-01

Attention-deficit/hyperactivity disorder (ADHD) is a pediatric psychological condition commonly treated with stimulant medications. Negative media reports and stigmatizing societal attitudes surrounding the use of these medications make it difficult for parents of affected children to accept stimulant treatment, despite it being first line therapy. The purpose of this study was to identify factors that influence parental decision making regarding stimulant treatment for ADHD. A systematic review of the literature was conducted to identify studies: 1) that employed qualitative methodology, 2) that highlighted treatment decision(s) about stimulant medication, 3) in which the decision(s) were made by the parent of a child with an official ADHD diagnosis, and 4) that examined the factors affecting the decision(s) made. Individual factors influencing parental treatment decision making, and the major themes encompassing these factors, were identified and followed by a thematic analysis. Eleven studies reporting on the experiences of 335 parents of children with ADHD were included. Four major themes encompassing influences on parents' decisions were derived from the thematic analysis performed: confronting the diagnosis, external influences, apprehension regarding therapy, and experience with the healthcare system. The findings of this systematic review reveal that there are multiple factors that influence parents' decisions about stimulant therapy. This information can assist clinicians in enhancing information delivery to parents of children with ADHD, and help reduce parental ambivalence surrounding stimulant medication use. Future work needs to address parental concerns about stimulants, and increase their involvement in shared decision making with clinicians to empower them to make the most appropriate treatment decision for their child.

Patients' Non-Medical Characteristics Contribute to Collective Medical Decision-Making at Multidisciplinary Oncological Team Meetings.

PubMed

Restivo, Léa; Apostolidis, Thémis; Bouhnik, Anne-Déborah; Garciaz, Sylvain; Aurran, Thérèse; Julian-Reynier, Claire

2016-01-01

The contribution of patients' non-medical characteristics to individual physicians' decision-making has attracted considerable attention, but little information is available on this topic in the context of collective decision-making. Medical decision-making at cancer centres is currently carried out using a collective approach, at MultiDisciplinary Team (MDT) meetings. The aim of this study was to determine how patients' non-medical characteristics are presented at MDT meetings and how this information may affect the team's final medical decisions. Observations were conducted at a French Cancer Centre during MDT meetings at which non-standard cases involving some uncertainty were discussed from March to May 2014. Physicians' verbal statements and predefined contextual parameters were collected with a non-participant observational approach. Non numerical data collected in the form of open notes were then coded for quantitative analysis. Univariate and multivariate statistical analyses were performed. In the final sample of patients' records included and discussed (N = 290), non-medical characteristics were mentioned in 32.8% (n = 95) of the cases. These characteristics corresponded to demographics in 22.8% (n = 66) of the cases, psychological data in 11.7% (n = 34), and relational data in 6.2% (n = 18). The patient's age and his/her "likeability" were the most frequently mentioned characteristics. In 17.9% of the cases discussed, the final decision was deferred: this outcome was positively associated with the patients' non-medical characteristics and with uncertainty about the outcome of the therapeutic options available. The design of the study made it difficult to draw definite cause-and-effect conclusions. The Social Representations approach suggests that patients' non-medical characteristics constitute a kind of tacit professional knowledge that may be frequently mobilised in physicians' everyday professional practice. The links observed between patients' attributes and the medical decisions made at these meetings show that these attributes should be taken into account in order to understand how medical decisions are reached in difficult situations of this kind.

Conceptualizing Surrogate Decision-Making at End of Life in the Intensive Care Unit using Cognitive Task Analysis

PubMed Central

Dionne-Odom, J. Nicholas; Willis, Danny G.; Bakitas, Marie; Crandall, Beth; Grace, Pamela J.

2014-01-01

Background Surrogate decision-makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. Purpose Identify and describe the underlying psychological processes of surrogate decision-making for adults at EOL in the ICU. Method Qualitative case study design using a cognitive task analysis (CTA) interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center’s ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semi-structured CTA interviews. Discussion The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions: gist impressions, distressing emotions, and moral intuitions impact a SDM’s judgment about the acceptability of either the patient’s medical treatments or his or her condition. Conclusion The framework offers initial insights about the underlying psychological processes of surrogate decision-making and may facilitate enhanced decision support for SDMs. PMID:25982772

Conceptualizing surrogate decision making at end of life in the intensive care unit using cognitive task analysis.

PubMed

Dionne-Odom, J Nicholas; Willis, Danny G; Bakitas, Marie; Crandall, Beth; Grace, Pamela J

2015-01-01

Surrogate decision makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. To identify and describe the underlying psychological processes of surrogate decision making for adults at EOL in the ICU. Qualitative case study design using a cognitive task analysis interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center's ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semistructured cognitive task analysis interviews. The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions (gist impressions, distressing emotions, and moral intuitions) impact an SDM's judgment about the acceptability of either the patient's medical treatments or his or her condition. The framework offers initial insights about the underlying psychological processes of surrogate decision making and may facilitate enhanced decision support for SDMs. Copyright © 2015 Elsevier Inc. All rights reserved.

Including values in evidence-based policy making for breast screening: An empirically grounded tool to assist expert decision makers.

PubMed

Parker, Lisa

2017-07-01

Values are an important part of evidence-based decision making for health policy: they guide the type of evidence that is collected, how it is interpreted, and how important the conclusions are considered to be. Experts in breast screening (including clinicians, researchers, consumer advocates and senior administrators) hold differing values in relation to what is important in breast screening policy and practice, and committees may find it difficult to incorporate the complexity and variety of values into policy decisions. The decision making tool provided here is intended to assist with this process. The tool is modified from more general frameworks that are intended to assist with ethical decision making in public health, and informed by data drawn from previous empirical studies on values amongst Australian breast screening experts. It provides a structured format for breast screening committees to consider and discuss the values of themselves and others, suggests relevant topics for further inquiry and highlights areas of need for future research into the values of the public. It enables committees to publicly explain and justify their decisions with reference to values, improving transparency and accountability. It is intended to act alongside practices that seek to accommodate the values of individual women in the informed decision making process for personal decision making about participation in breast screening. Copyright © 2017 Elsevier B.V. All rights reserved.

[Diagnosis and treatment guidelines for difficult-to-control asthma in children].

PubMed

Navarro Merino, M; Andrés Martín, A; Asensio de la Cruz, O; García García, M L; Liñán Cortes, S; Villa Asensi, J R

2009-12-01

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.

Towards ethical decision support and knowledge management in neonatal intensive care.

PubMed

Yang, L; Frize, M; Eng, P; Walker, R; Catley, C

2004-01-01

Recent studies in neonatal medicine, clinical nursing, and cognitive psychology have indicated the need to augment current decision-making practice in neonatal intensive care units with computerized, intelligent decision support systems. Rapid progress in artificial intelligence and knowledge management facilitates the design of collaborative ethical decision-support tools that allow clinicians to provide better support for parents facing inherently difficult choices, such as when to withdraw aggressive treatment. The appropriateness of using computers to support ethical decision-making is critically analyzed through research and literature review. In ethical dilemmas, multiple diverse participants need to communicate and function as a team to select the best treatment plan. In order to do this, physicians require reliable estimations of prognosis, while parents need a highly useable tool to help them assimilate complex medical issues and address their own value system. Our goal is to improve and structuralize the ethical decision-making that has become an inevitable part of modern neonatal care units. The paper contributes to clinical decision support by outlining the needs and basis for ethical decision support and justifying the proposed development efforts.

Local public health resource allocation: limited choices and strategic decisions.

PubMed

Bekemeier, Betty; Chen, Anthony L-T; Kawakyu, Nami; Yang, Youngran

2013-12-01

Local health department leaders are expected to improve the health of their populations as they "use and contribute to" the evidence base for practice, but effectively providing and utilizing data and evidence for local public health decision making has proven difficult. This study was conducted in 2011 and initiated by Washington State's public health practice-based research network to identify factors influencing local resource allocation and programmatic decisions among public health leaders facing severe funding losses. Quantitative data informed sampling for the collection of interview data. Qualitative methods were used to capture diverse insights of Washington State's local public health leaders in making decisions regarding resource allocation. Local decision-making authority was perceived as greatly restricted by what public health activities were legally mandated and the categoric nature of funding sources, even as some leaders exercised deliberate strategic approaches. One's workforce and board of health were also influential in making decisions regarding resource allocations. Challenges were expressed regarding making use of data and research evidence for decision making. Data were analyzed in 2011-2012. Programmatic mandates, funding restrictions, local stakeholders, and workforce capacity appear to trump factors such as research evidence and perceived community need in public health resource allocation. Study findings highlight tensions between the literature descriptions of what "should" influence decision making in local public health and the realities of practice. Advancements in practice-based research and evidence-based decision making, however, provide opportunities for strengthening the development of evidence and research translation for local decision making to maximize resources and promote effective service provision. © 2013 American Journal of Preventive Medicine Published by American Journal of Preventive Medicine All rights reserved.

Surrogate decision making: do we have to trade off accuracy and procedural satisfaction?

PubMed

Frey, Renato; Hertwig, Ralph; Herzog, Stefan M

2014-02-01

Making surrogate decisions on behalf of incapacitated patients can raise difficult questions for relatives, physicians, and society. Previous research has focused on the accuracy of surrogate decisions (i.e., the proportion of correctly inferred preferences). Less attention has been paid to the procedural satisfaction that patients' surrogates and patients attribute to specific approaches to making surrogate decisions. The objective was to investigate hypothetical patients' and surrogates' procedural satisfaction with specific approaches to making surrogate decisions and whether implementing these preferences would lead to tradeoffs between procedural satisfaction and accuracy. Study 1 investigated procedural satisfaction by assigning participants (618 in a mixed-age but relatively young online sample and 50 in an older offline sample) to the roles of hypothetical surrogates or patients. Study 2 (involving 64 real multigenerational families with a total of 253 participants) investigated accuracy using 24 medical scenarios. Hypothetical patients and surrogates had closely aligned preferences: Procedural satisfaction was highest with a patient-designated surrogate, followed by shared surrogate decision-making approaches and legally assigned surrogates. These approaches did not differ substantially in accuracy. Limitations are that participants' preferences regarding existing and novel approaches to making surrogate decisions can only be elicited under hypothetical conditions. Next to decision making by patient-designated surrogates, shared surrogate decision making is the preferred approach among patients and surrogates alike. This approach appears to impose no tradeoff between procedural satisfaction and accuracy. Therefore, shared decision making should be further studied in representative samples of the general population, and if people's preferences prove to be robust, they deserve to be weighted more strongly in legal frameworks in addition to patient-designated surrogates.

Angina Treatment: Stents, Drugs, Lifestyle Changes -- What's Best?

MedlinePlus

... doctor may recommend angioplasty or coronary bypass surgery. Making a decision on how to treat your angina can be difficult, but knowing the benefits and risks of stents and medications may help ...

Everyday ethics: learning from an ‘ordinary’ consultation in general practice

PubMed Central

2011-01-01

The author uses a constructed case to analyse some of the ethical decisions that UK general practitioners face in everyday settings. A variety of ethical frameworks and empirical primary healthcare literature are used to demonstrate how ethical tools may be used by clinicians in primary healthcare to reflect on their decisions in practice. The GP consultation context can make ‘on the spot’ ethical decisions difficult and varied. PMID:25949652

[Ethics, empiricism and uncertainty].

PubMed

Porz, R; Zimmermann, H; Exadaktylos, A K

2011-01-01

Accidents can lead to difficult boundary situations. Such situations often take place in the emergency units. The medical team thus often and inevitably faces professional uncertainty in their decision-making. It is essential to communicate these uncertainties within the medical team, instead of downplaying or overriding existential hurdles in decision-making. Acknowledging uncertainties might lead to alert and prudent decisions. Thus uncertainty can have ethical value in treatment or withdrawal of treatment. It does not need to be covered in evidence-based arguments, especially as some singular situations of individual tragedies cannot be grasped in terms of evidence-based medicine. © Georg Thieme Verlag KG Stuttgart · New York.

Cochlear Implant: the complexity involved in the decision making process by the family.

PubMed

Vieira, Sheila de Souza; Bevilacqua, Maria Cecília; Ferreira, Noeli Marchioro Liston Andrade; Dupas, Giselle

2014-01-01

to understand the meanings the family attributes to the phases of the decision-making process on a cochlear implant for their child. qualitative research, using Symbolic Interactionism and Grounded Theory as the theoretical and methodological frameworks, respectively. Data collection instrument: semistructured interview. Nine families participated in the study (32 participants). knowledge deficit, difficulties to contextualize benefits and risks and fear are some factors that make this process difficult. Experiences deriving from interactions with health professionals, other cochlear implant users and their relatives strengthen decision making in favor of the implant. deciding on whether or not to have the implant involves a complex process, in which the family needs to weigh gains and losses, experience feelings of accountability and guilt, besides overcoming the risk aversion. Hence, this demands cautious preparation and knowledge from the professionals involved in this intervention.

Effect of Integrating Hydrologic Scaling Concepts on Students Learning and Decision Making Experiences

ERIC Educational Resources Information Center

Najm, Majdi R. Abou; Mohtar, Rabi H.; Cherkauer, Keith A.; French, Brian F.

2010-01-01

Proper understanding of scaling and large-scale hydrologic processes is often not explicitly incorporated in the teaching curriculum. This makes it difficult for students to connect the effect of small scale processes and properties (like soil texture and structure, aggregation, shrinkage, and cracking) on large scale hydrologic responses (like…

Supporting Collaboration with Technology: Does Shared Cognition Lead to Co-Regulation in Medicine?

ERIC Educational Resources Information Center

Lajoie, Susanne P.; Lu, Jingyan

2012-01-01

The theoretical distinctions between metacognition, self-regulation and self-regulated learning are often blurred which makes the definition of co-regulation in group learning situations even more difficult. We have started to explore co-regulation in the context of decision making in simulated emergencies where medical teams work together to…

Thankless but Vital: The Role of the Faculty Senate Chair

ERIC Educational Resources Information Center

Hubbell, Larry

2010-01-01

Despite trends toward greater corporatism and bureaucratization of the academy, some vestiges of shared governance remain, including some level of faculty decision-making in faculty senates or councils. Generalizations about faculty senates are difficult to make because they vary with regard to their level of power and faculty involvement.…

Making It Real: Using a Collaborative Simulation to Teach Crisis Communications

ERIC Educational Resources Information Center

Olson, K. S.

2012-01-01

Even seasoned public relations (PR) practitioners can find it difficult to handle communications during a crisis situation when the consequences of making poor decisions may seem overwhelming. This article shares results from using a collaborative simulation to teach college students about crisis communications in an advanced-level PR course.…

Mechanisms Underlying Decision-Making as Revealed by Deep-Brain Stimulation in Patients with Parkinson's Disease.

PubMed

Herz, Damian M; Little, Simon; Pedrosa, David J; Tinkhauser, Gerd; Cheeran, Binith; Foltynie, Tom; Bogacz, Rafal; Brown, Peter

2018-04-23

To optimally balance opposing demands of speed and accuracy during decision-making, we must flexibly adapt how much evidence we require before making a choice. Such adjustments in decision thresholds have been linked to the subthalamic nucleus (STN), and therapeutic STN deep-brain stimulation (DBS) has been shown to interfere with this function. Here, we performed continuous as well as closed-loop DBS of the STN while Parkinson's disease patients performed a perceptual decision-making task. Closed-loop STN DBS allowed temporally patterned STN stimulation and simultaneous recordings of STN activity. This revealed that DBS only affected patients' ability to adjust decision thresholds if applied in a specific temporally confined time window during deliberation. Only stimulation in that window diminished the normal slowing of response times that occurred on difficult trials when DBS was turned off. Furthermore, DBS eliminated a relative, time-specific increase in STN beta oscillations and compromised its functional relationship with trial-by-trial adjustments in decision thresholds. Together, these results provide causal evidence that the STN is involved in adjusting decision thresholds in distinct, time-limited processing windows during deliberation. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.

Valuing information for sewer replacement decisions.

PubMed

van Riel, Wouter; Langeveld, Jeroen; Herder, Paulien; Clemens, François

Decision-making for sewer asset management is partially based on intuition and often lacks explicit argumentation, hampering decision transparency and reproducibility. This is not to be preferred in light of public accountability and cost-effectiveness. It is unknown to what extent each decision criterion is appreciated by decision-makers. Further insight into this relative importance improves understanding of decision-making of sewer system managers. As such, a digital questionnaire (response ratio 43%), containing pairwise comparisons between 10 relevant information sources, was sent to all 407 municipalities in the Netherlands to analyse the relative importance and assess whether a shared frame of reasoning is present. Thurstone's law of comparative judgment was used for analysis, combined with several consistency tests. Results show that camera inspections were valued highest, while pipe age was considered least important. The respondents were pretty consistent per individual and also showed consistency as a group. This indicated a common framework of reasoning among the group. The feedback of the group showed, however, the respondents found it difficult to make general comparisons without having a context. This indicates decision-making in practice is more likely to be steered by other mechanisms than purely combining information sources.

Working with interpreters: The challenges of introducing Option Grid patient decision aids.

PubMed

Wood, Fiona; Phillips, Katie; Edwards, Adrian; Elwyn, Glyn

2017-03-01

We aimed to observe how an Option Grid™ decision aid for clinical encounters might be used where an interpreter is present, and to assess the impact of its use on shared decision making. Data were available from three clinical consultations between patient, clinician (a physiotherapist), and interpreter about knee osteoarthritis. Clinicians were trained in the use of an Option Grid decision aid and the tool was used. Consultations were audio-recorded, transcribed, and translated by independent translators into English. Analysis revealed the difficulties with introducing a written decision aid into an interpreted consultation. The extra discussion needed between the clinician and interpreter around the principles and purpose of shared decision making and instructions regarding the Option Grid decision aid proved challenging and difficult to manage. Discussion of treatment options while using an Option Grid decision aid was predominantly done between clinician and interpreter. The patient appeared to have little involvement in discussion of treatment options. Patients were not active participants within the discussion. Further work needs to be done on how shared decision making can be achieved within interpreted consultations. Option Grid decision aids are not being used as intended in interpreted consultations. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Pain relief in labour: a qualitative study to determine how to support women to make decisions about pain relief in labour

PubMed Central

2014-01-01

Background Engagement in decision making is a key priority of modern healthcare. Women are encouraged to make decisions about pain relief in labour in the ante-natal period based upon their expectations of what labour pain will be like. Many women find this planning difficult. The aim of this qualitative study was to explore how women can be better supported in preparing for, and making, decisions during pregnancy and labour regarding pain management. Methods Semi-structured interviews were conducted with 13 primiparous and 10 multiparous women at 36 weeks of pregnancy and again within six weeks postnatally. Data collection and analysis occurred concurrently to identify key themes. Results Three main themes emerged from the data. Firstly, during pregnancy women expressed a degree of uncertainty about the level of pain they would experience in labour and the effect of different methods of pain relief. Secondly, women reflected on how decisions had been made regarding pain management in labour and the degree to which they had felt comfortable making these decisions. Finally, women discussed their perceived levels of control, both desired and experienced, over both their bodies and the decisions they were making. Conclusion This study suggests that the current approach of antenatal preparation in the NHS, of asking women to make decisions antenatally for pain relief in labour, needs reviewing. It would be more beneficial to concentrate efforts on better informing women and on engaging them in discussions around their values, expectations and preferences and how these affect each specific choice rather than expecting them to make to make firm decisions in advance of such an unpredictable event as labour. PMID:24397421

An interval-valued 2-tuple linguistic group decision-making model based on the Choquet integral operator

NASA Astrophysics Data System (ADS)

Liu, Bingsheng; Fu, Meiqing; Zhang, Shuibo; Xue, Bin; Zhou, Qi; Zhang, Shiruo

2018-01-01

The Choquet integral (IL) operator is an effective approach for handling interdependence among decision attributes in complex decision-making problems. However, the fuzzy measures of attributes and attribute sets required by IL are difficult to achieve directly, which limits the application of IL. This paper proposes a new method for determining fuzzy measures of attributes by extending Marichal's concept of entropy for fuzzy measure. To well represent the assessment information, interval-valued 2-tuple linguistic context is utilised to represent information. Then, we propose a Choquet integral operator in an interval-valued 2-tuple linguistic environment, which can effectively handle the correlation between attributes. In addition, we apply these methods to solve multi-attribute group decision-making problems. The feasibility and validity of the proposed operator is demonstrated by comparisons with other models in illustrative example part.

Intelligent data management for real-time spacecraft monitoring

NASA Technical Reports Server (NTRS)

Schwuttke, Ursula M.; Gasser, Les; Abramson, Bruce

1992-01-01

Real-time AI systems have begun to address the challenge of restructuring problem solving to meet real-time constraints by making key trade-offs that pursue less than optimal strategies with minimal impact on system goals. Several approaches for adapting to dynamic changes in system operating conditions are known. However, simultaneously adapting system decision criteria in a principled way has been difficult. Towards this end, a general technique for dynamically making such trade-offs using a combination of decision theory and domain knowledge has been developed. Multi-attribute utility theory (MAUT), a decision theoretic approach for making one-time decisions is discussed and dynamic trade-off evaluation is described as a knowledge-based extension of MAUT that is suitable for highly dynamic real-time environments, and provides an example of dynamic trade-off evaluation applied to a specific data management trade-off in a real-world spacecraft monitoring application.

Gender, households, and decision-making for wildfire safety.

PubMed

Tyler, Meagan; Fairbrother, Peter

2018-03-13

This paper considers the impact of gendered norms on decision-making for wildfire preparation and response at the household level. Focusing on Australia, it provides a theoretical thematic analysis of data acquired in 107 interviews with residents of nine different localities. It builds on existing research on gender and disaster, as well as on decision-making and wildfires, and analyses the narratives that centre on 'split' households plans (where a male partner plans to stay and a female partner plans to evacuate) and disagreements within heterosexual couples as to an appropriate wildfire safety plan. The study finds that gender inequality and differences in gendered expectations are likely to create difficult conditions for negotiation between members of a heterosexual couple when there is disagreement over a plan and that this may contribute to risky decision-making practices and outcomes. The paper reiterates, therefore, the importance of taking into account the social construction of gender in wildfire research and policy. © 2018 The Author(s). Disasters © Overseas Development Institute, 2018.

Uncharted terrain: preference construction at the end of life.

PubMed

White, Mary T

2014-01-01

Respect for patients' self-determination has long been considered central to efforts to improve end-of-life care, yet efforts to promote advance directives or engage patients in end-of-life discussions are often unsuccessful. In this article, I contend that this is because the shared decision-making approach typically used in healthcare assumes patients' capacity to make rational choices, which is not always possible in end-of-life decisions. Drawing on decision theory, behavioral psychology, and related studies of end-of-life care, I present a growing body of evidence that suggests the novelty, complexity, and uncertainty of end-of-life circumstances make rational and stable preferences difficult to establish. I argue that an effective decision-making approach for the terminally ill must recognize and respond to the unique characteristics of end-of-life choices, including their nonrational dimensions. I conclude with a description of an initiative that appears to do so, resulting in increased patients' satisfaction. Copyright 2014 The Journal of Clinical Ethics. All rights reserved.

Current Use of Evidence-Based Medicine in Pediatric Spine Surgery.

PubMed

Oetgen, Matthew E

2018-04-01

Evidence-based medicine (EBM) is a process of decision-making aimed at making the best clinical decisions as they relate to patients' health. The current use of EBM in pediatric spine surgery is varied, based mainly on the availability of high-quality data. The use of EBM is limited in idiopathic scoliosis, whereas EBM has been used to investigate the treatment of pediatric spondylolysis. Studies on early onset scoliosis are of low quality, making EBM difficult in this condition. Future focus and commitment to study quality in pediatric spinal surgery will likely increase the role of EBM in these conditions. Copyright © 2017 Elsevier Inc. All rights reserved.

Recruiting patients to clinical trials: lessons from studies of growth hormone treatment in renal failure.

PubMed

Postlethwaite, R J; Reynolds, J M; Wood, A J; Evans, J H; Lewis, M A; Eminson, D M

1995-07-01

Issues raised by the recruitment of children to trials of growth hormone treatment for short stature in chronic renal failure are reported. Information needs of parents and children are discussed, the latter should take account of the children's developmental level and anticipated involvement in decision making. When the incidence of certain side effects is low and probably unquantifiable there are particular problems; failure to include these in information sheets may compromise informed consent but inclusion will, at least for some families, make an already difficult decision even more complicated. A process of recruitment is described which attempts to protect against bias and which balances the requirement to impart neutral information with appropriate clinical involvement in the decision to enter the study. Other functions of the recruitment process are identified. Analysis of understanding and decision making demonstrates that good understanding is neither necessary nor sufficient for ease of decision making. The recruitment process was time consuming and needs planning and funding in future studies. Many of these issues are of general importance for trials of treatment in children.

Parents and end-of-life decision-making for their child: roles and responsibilities.

PubMed

Sullivan, Jane; Gillam, Lynn; Monagle, Paul

2015-09-01

Whether parents want to be and should be the decision-maker for their child in end-of-life matters are contested clinical and ethical questions. Previous research outcomes are equivocal. A qualitative interview method was used to examine the views and experiences of 25 bereaved parents in end-of-life decision-making for their child. Data were analysed thematically. Three types of decision-making roles were identified: self-determined, guided (both involving active decision-making) and acquiescent (passive).The majority of parents had been active in the decision-making process for their child. They perceived themselves as the ultimate end-of-life decision-maker. This was perceived as part of their parental responsibility. A minority of parents did not consider that they had been an active, ultimate decision-maker. Generally, parents in the self-determined and guided groups reported no negative consequences from their decision-making involvement. Importantly, parents in the acquiescent group described their experience as difficult at the time and subsequently, although not all difficulties related directly to decision-making. Parents considered that in principle parents should be the end-of-life decision-maker for their child, but understood personal characteristics and preference could prevent some parents from taking this role. This study unequivocally supports parents' desire to fulfil the end-of-life decision-making role. It provides a nuanced understanding of parents' roles and contributes evidence for the ethical position that parents should be the end-of-life decision-makers for their child, unless not in the child's best interests. On the whole, parents want this role and can manage its consequences. Indeed, not being the end-of-life decision-maker could be detrimental to parents' well-being. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Decision-making under risk in children, adolescents, and young adults.

PubMed

Paulsen, David J; Platt, Michael L; Huettel, Scott A; Brannon, Elizabeth M

2011-01-01

Adolescents often make risky and impulsive decisions. Such behavior has led to the common assumption that a dysfunction in risk-related decision-making peaks during this age. Differences in how risk has been defined across studies, however, make it difficult to draw conclusions about developmental changes in risky decision-making. Here, we developed a non-symbolic economic decision-making task that can be used across a wide age span and that uses coefficient of variation (CV) in reward as an index of risk. We found that young children showed the strongest preference for risky compared to sure bet options of equal expected value, adolescents were intermediate in their risk preference, and young adults showed the strongest risk aversion. Furthermore, children's preference for the risky option increased for larger CVs, while adolescents and young adults showed the opposite pattern, favoring the sure bet more often as CV increased. Finally, when faced with two gambles in a risk-return tradeoff, all three age groups exhibited a greater preference for the option with the lower risk and return as the disparity in risk between the two options increased. These findings demonstrate clear age-related differences in economic risk preferences that vary with choice set and risk. Importantly, adolescence appears to represent an intermediate decision-making phenotype along the transition from childhood to adulthood, rather than an age of heightened preference for economic risk.

Decision-Making Under Risk in Children, Adolescents, and Young Adults

PubMed Central

Paulsen, David J.; Platt, Michael L.; Huettel, Scott A.; Brannon, Elizabeth M.

2011-01-01

Adolescents often make risky and impulsive decisions. Such behavior has led to the common assumption that a dysfunction in risk-related decision-making peaks during this age. Differences in how risk has been defined across studies, however, make it difficult to draw conclusions about developmental changes in risky decision-making. Here, we developed a non-symbolic economic decision-making task that can be used across a wide age span and that uses coefficient of variation (CV) in reward as an index of risk. We found that young children showed the strongest preference for risky compared to sure bet options of equal expected value, adolescents were intermediate in their risk preference, and young adults showed the strongest risk aversion. Furthermore, children's preference for the risky option increased for larger CVs, while adolescents and young adults showed the opposite pattern, favoring the sure bet more often as CV increased. Finally, when faced with two gambles in a risk–return tradeoff, all three age groups exhibited a greater preference for the option with the lower risk and return as the disparity in risk between the two options increased. These findings demonstrate clear age-related differences in economic risk preferences that vary with choice set and risk. Importantly, adolescence appears to represent an intermediate decision-making phenotype along the transition from childhood to adulthood, rather than an age of heightened preference for economic risk. PMID:21687443

Family factors affect clinician attitudes in pediatric end-of-life decision making: a randomized vignette study.

PubMed

Ruppe, Michael D; Feudtner, Chris; Hexem, Kari R; Morrison, Wynne E

2013-05-01

Conflicts between families and clinicians in pediatric end-of-life (EOL) care cause distress for providers, dissatisfaction for patients' families, and potential suffering for terminally ill children. We hypothesized that family factors might influence clinician decision making in these circumstances. We presented vignettes concerning difficult EOL decision making, randomized for religious objection to therapy withdrawal and perceived level of family involvement, to clinicians working in three Children's Hospital intensive care units. Additionally, attitudes about EOL care were assessed. Three hundred sixty-four respondents completed the questionnaire, for an overall response rate of 54%. Respondents receiving the "involved family" vignette were more likely to agree to continue medical care indefinitely (P<0.0005). Respondents were marginally more likely to pursue a court-appointed guardian for those patients whose families had nonreligious objections to withdrawal (P=0.05). Respondents who thought that a fear of being sued affected decisions were less likely to pursue unilateral withdrawal (odds ratio 0.8, 95% CI=0.6-0.9). Those who felt personal distress as a result of difficult EOL decision making, thought they often provided "futile" care, or those who felt EOL care was effectively addressed at the institution were less likely to want to defer to the parents' wishes (range of odds ratios 0.7-1). In this randomized vignette study, we have shown that family factors, particularly how involved a family seems to be in a child's life, affect what clinicians think is ethically appropriate in challenging EOL cases. Knowledge of how a family's degree of involvement may affect clinicians should be helpful to the clinical ethics consultants and offer some degree of insight to the clinicians themselves. Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Use of antipsychotic blood levels in clinician decision making: A cross-over study using clinical vignettes of patients with schizophrenia.

PubMed

Savitz, Adam; Melkote, Rama; Riley, Ralph; Pobre, Maria A; McQuarrie, Kelly; Williamson, David; Banderas, Benjamin

2018-05-19

The cause of treatment failure of antipsychotic medications is often difficult to determine in patients with schizophrenia. Evaluation of antipsychotic blood levels (ABLs) may aid clinicians in determining the cause of antipsychotic failure. The Clinical Assessment of the Schizophrenia Patient (CASP) was developed to evaluate clinical decision making during outpatient visits. The CASP assesses changes in medications, psychosocial treatments, and acute interventions along with factors influencing clinical decision making. Nine vignettes representative of clinical situations in patients with schizophrenia were created in two versions (one with ABLs, one without ABLs). The CASP was used to evaluate clinical decisions using the vignettes. Thirty-four clinicians participated in the study. In 8 out of 9 vignettes, most clinicians (at least 89.7%) made a different clinical decision with ABLs compared to without ABLs. In assessing the usefulness of ABLs, a majority (60.7%-85.7%, depending on the vignette) of clinicians responded that ABLs changed their clinical decision for 8 vignettes. Most clinicians (79%-93%) responded that they were more confident in their decisions with ABL information. This study demonstrated that ABLs have the potential to influence clinical decision making in the treatment of patients with schizophrenia. Copyright © 2018. Published by Elsevier B.V.

Decision-making in crisis: Applying a healthcare triage methodology to business continuity management.

PubMed

Moore, Bethany; Bone, Eric A

2017-01-01

The concept of triage in healthcare has been around for centuries and continues to be applied today so that scarce resources are allocated according to need. A business impact analysis (BIA) is a form of triage in that it identifies which processes are most critical, which to address first and how to allocate limited resources. On its own, however, the BIA provides only a roadmap of the impacts and interdependencies of an event. When disaster strikes, organisational decision-makers often face difficult decisions with regard to allocating limited resources between multiple 'mission-critical' functions. Applying the concept of triage to business continuity provides those decision-makers navigating a rapidly evolving and unpredictable event with a path that protects the fundamental priorities of the organisation. A business triage methodology aids decision-makers in times of crisis by providing a simplified framework for decision-making based on objective, evidence-based criteria, which is universally accepted and understood. When disaster strikes, the survival of the organisation depends on critical decision-making and quick actions to stabilise the incident. This paper argues that organisations need to supplement BIA processes with a decision-making triage methodology that can be quickly applied during the chaos of an actual event.

Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care.

PubMed

Burke, Robert E; Jones, Jacqueline; Lawrence, Emily; Ladebue, Amy; Ayele, Roman; Leonard, Chelsea; Lippmann, Brandi; Matlock, Daniel D; Allyn, Rebecca; Cumbler, Ethan

2018-05-01

Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization. We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF. Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making. Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities. We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame. The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome. Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.

Overcoming status quo bias in the human brain.

PubMed

Fleming, Stephen M; Thomas, Charlotte L; Dolan, Raymond J

2010-03-30

Humans often accept the status quo when faced with conflicting choice alternatives. However, it is unknown how neural pathways connecting cognition with action modulate this status quo acceptance. Here we developed a visual detection task in which subjects tended to favor the default when making difficult, but not easy, decisions. This bias was suboptimal in that more errors were made when the default was accepted. A selective increase in subthalamic nucleus (STN) activity was found when the status quo was rejected in the face of heightened decision difficulty. Analysis of effective connectivity showed that inferior frontal cortex, a region more active for difficult decisions, exerted an enhanced modulatory influence on the STN during switches away from the status quo. These data suggest that the neural circuits required to initiate controlled, nondefault actions are similar to those previously shown to mediate outright response suppression. We conclude that specific prefrontal-basal ganglia dynamics are involved in rejecting the default, a mechanism that may be important in a range of difficult choice scenarios.

Goal-Directed Decision Making with Spiking Neurons.

PubMed

Friedrich, Johannes; Lengyel, Máté

2016-02-03

Behavioral and neuroscientific data on reward-based decision making point to a fundamental distinction between habitual and goal-directed action selection. The formation of habits, which requires simple updating of cached values, has been studied in great detail, and the reward prediction error theory of dopamine function has enjoyed prominent success in accounting for its neural bases. In contrast, the neural circuit mechanisms of goal-directed decision making, requiring extended iterative computations to estimate values online, are still unknown. Here we present a spiking neural network that provably solves the difficult online value estimation problem underlying goal-directed decision making in a near-optimal way and reproduces behavioral as well as neurophysiological experimental data on tasks ranging from simple binary choice to sequential decision making. Our model uses local plasticity rules to learn the synaptic weights of a simple neural network to achieve optimal performance and solves one-step decision-making tasks, commonly considered in neuroeconomics, as well as more challenging sequential decision-making tasks within 1 s. These decision times, and their parametric dependence on task parameters, as well as the final choice probabilities match behavioral data, whereas the evolution of neural activities in the network closely mimics neural responses recorded in frontal cortices during the execution of such tasks. Our theory provides a principled framework to understand the neural underpinning of goal-directed decision making and makes novel predictions for sequential decision-making tasks with multiple rewards. Goal-directed actions requiring prospective planning pervade decision making, but their circuit-level mechanisms remain elusive. We show how a model circuit of biologically realistic spiking neurons can solve this computationally challenging problem in a novel way. The synaptic weights of our network can be learned using local plasticity rules such that its dynamics devise a near-optimal plan of action. By systematically comparing our model results to experimental data, we show that it reproduces behavioral decision times and choice probabilities as well as neural responses in a rich set of tasks. Our results thus offer the first biologically realistic account for complex goal-directed decision making at a computational, algorithmic, and implementational level. Copyright © 2016 the authors 0270-6474/16/361529-18$15.00/0.

Goal-Directed Decision Making with Spiking Neurons

PubMed Central

Lengyel, Máté

2016-01-01

Behavioral and neuroscientific data on reward-based decision making point to a fundamental distinction between habitual and goal-directed action selection. The formation of habits, which requires simple updating of cached values, has been studied in great detail, and the reward prediction error theory of dopamine function has enjoyed prominent success in accounting for its neural bases. In contrast, the neural circuit mechanisms of goal-directed decision making, requiring extended iterative computations to estimate values online, are still unknown. Here we present a spiking neural network that provably solves the difficult online value estimation problem underlying goal-directed decision making in a near-optimal way and reproduces behavioral as well as neurophysiological experimental data on tasks ranging from simple binary choice to sequential decision making. Our model uses local plasticity rules to learn the synaptic weights of a simple neural network to achieve optimal performance and solves one-step decision-making tasks, commonly considered in neuroeconomics, as well as more challenging sequential decision-making tasks within 1 s. These decision times, and their parametric dependence on task parameters, as well as the final choice probabilities match behavioral data, whereas the evolution of neural activities in the network closely mimics neural responses recorded in frontal cortices during the execution of such tasks. Our theory provides a principled framework to understand the neural underpinning of goal-directed decision making and makes novel predictions for sequential decision-making tasks with multiple rewards. SIGNIFICANCE STATEMENT Goal-directed actions requiring prospective planning pervade decision making, but their circuit-level mechanisms remain elusive. We show how a model circuit of biologically realistic spiking neurons can solve this computationally challenging problem in a novel way. The synaptic weights of our network can be learned using local plasticity rules such that its dynamics devise a near-optimal plan of action. By systematically comparing our model results to experimental data, we show that it reproduces behavioral decision times and choice probabilities as well as neural responses in a rich set of tasks. Our results thus offer the first biologically realistic account for complex goal-directed decision making at a computational, algorithmic, and implementational level. PMID:26843636

Systems thinking, complexity and managerial decision-making: an analytical review.

PubMed

Cramp, D G; Carson, E R

2009-05-01

One feature that characterizes the organization and delivery of health care is its inherent complexity. All too often, with so much information and so many activities involved, it is difficult for decision-makers to determine in an objective fashion an appropriate course of action. It would appear that a holistic rather than a reductionist approach would be advantageous. The aim of this paper is to review how formal systems thinking can aid decision-making in complex situations. Consideration is given as to how the use of a number of systems modelling methodologies can help in gaining an understanding of a complex decision situation. This in turn can enhance the possibility of a decision being made in a more rational, explicit and transparent fashion. The arguments and approaches are illustrated using examples taken from the public health arena.

Expert-novice differences in cognitive and execution skills during tennis competition.

PubMed

Del Villar, Fernando; García González, Luis; Iglesias, Damián; Perla Moreno, M; Cervelló, Eduardo M

2007-04-01

This study deals with decision and execution behavior of tennis players during competition. The study is based on the expert-novice paradigm and aims to identify differences between both groups in the decision-making and execution variables in serve and shot actions in tennis. Six expert players (elite Spanish tennis players) and six novice players (grade school tennis players) took part in this study. To carry out this study, the observation protocol defined by McPherson and Thomas in 1989, in which control, decision-making and execution variables were included, was used, where it was applied to the performance of the tennis player in a real match situation. In the analysis, significant differences between experts and novices in decision-making and execution variables are found wherein it can be observed that experts display a greater ability to make the appropriate decisions, selecting the most tactical responses to put pressure on the opponent. Expert tennis players were also able to carry out forceful executions to their opponent with greater efficiency, making the opponent's response to a large extent more difficult. These findings are in accordance with those of McPherson and colleagues.

Choice Set Size and Decision-Making: The Case of Medicare Part D Prescription Drug Plans

PubMed Central

Bundorf, M. Kate; Szrek, Helena

2013-01-01

Background The impact of choice on consumer decision-making is controversial in U.S. health policy. Objective Our objective was to determine how choice set size influences decision-making among Medicare beneficiaries choosing prescription drug plans. Methods We randomly assigned members of an internet-enabled panel age 65 and over to sets of prescription drug plans of varying sizes (2, 5, 10, and 16) and asked them to choose a plan. Respondents answered questions about the plan they chose, the choice set, and the decision process. We used ordered probit models to estimate the effect of choice set size on the study outcomes. Results Both the benefits of choice, measured by whether the chosen plan is close to the ideal plan, and the costs, measured by whether the respondent found decision-making difficult, increased with choice set size. Choice set size was not associated with the probability of enrolling in any plan. Conclusions Medicare beneficiaries face a tension between not wanting to choose from too many options and feeling happier with an outcome when they have more alternatives. Interventions that reduce cognitive costs when choice sets are large may make this program more attractive to beneficiaries. PMID:20228281

Bayesian Decision Support

NASA Astrophysics Data System (ADS)

Berliner, M.

2017-12-01

Bayesian statistical decision theory offers a natural framework for decision-policy making in the presence of uncertainty. Key advantages of the approach include efficient incorporation of information and observations. However, in complicated settings it is very difficult, perhaps essentially impossible, to formalize the mathematical inputs needed in the approach. Nevertheless, using the approach as a template is useful for decision support; that is, organizing and communicating our analyses. Bayesian hierarchical modeling is valuable in quantifying and managing uncertainty such cases. I review some aspects of the idea emphasizing statistical model development and use in the context of sea-level rise.

Cochlear Implant: the complexity involved in the decision making process by the family1

PubMed Central

Vieira, Sheila de Souza; Bevilacqua, Maria Cecília; Ferreira, Noeli Marchioro Liston Andrade; Dupas, Giselle

2014-01-01

Objective to understand the meanings the family attributes to the phases of the decision-making process on a cochlear implant for their child. Method qualitative research, using Symbolic Interactionism and Grounded Theory as the theoretical and methodological frameworks, respectively. Data collection instrument: semistructured interview. Nine families participated in the study (32 participants). Results knowledge deficit, difficulties to contextualize benefits and risks and fear are some factors that make this process difficult. Experiences deriving from interactions with health professionals, other cochlear implant users and their relatives strengthen decision making in favor of the implant. Conclusion deciding on whether or not to have the implant involves a complex process, in which the family needs to weigh gains and losses, experience feelings of accountability and guilt, besides overcoming the risk aversion. Hence, this demands cautious preparation and knowledge from the professionals involved in this intervention. PMID:25029052

From Assessment to Annual Goal: Engaging a Decision-Making Process in Writing Measurable IEPs

ERIC Educational Resources Information Center

Capizzi, Andrea M.

2008-01-01

Despite federal regulations requiring measurable individualized education programs (IEPs), IEPs are often vague and unfocused, making them difficult to use in guiding instructional planning. Although a well-written IEP can be time consuming and labor intensive, a clearly written IEP, based on documented student needs, can and should be a guidepost…

Making Sense of Abstinence

ERIC Educational Resources Information Center

Taverner, Bill; Montfort, Sue

2011-01-01

Young people need to know that abstinence is a far more complex, difficult concept than it is often portrayed. Abstinence is a decision about sexual behaviors that a person may make throughout his or her life. It is a choice made at a specific time in a specific situation, for a specific period of time, whether one is in a partnered relationship…

Climate change effects in El Yunque National Forest, Puerto Rico, and the Caribbean region

Treesearch

Lisa Nicole Jennings; Jamison Douglas; Emrys Treasure; Grizelle González

2014-01-01

Understanding the current and expected future conditions of natural resources under a changing climate is essential to making informed management decisions. However, the ever increasing volume of useful scientific information about climate change makes it difficult for managers and planners to effectively sort through and apply the emerging science. This report...

Institutional Research in the USA: Adapting to Meet New Challenges

ERIC Educational Resources Information Center

Swing, Randy L.

2009-01-01

The varied roles and scope of the field of institutional research (IR) make any overview of this administrative function difficult. In the USA, colleges and universities may have a large, well-defined administrative unit performing data tasks to support decision-making, or they may have only a part-time individual who coordinates basic reporting…

Current understanding of decision-making in adolescents with cancer: A narrative systematic review

PubMed Central

Day, Emma; Jones, Louise; Langner, Richard; Bluebond-Langner, Myra

2016-01-01

Background: Policy guidance and bioethical literature urge the involvement of adolescents in decisions about their healthcare. It is uncertain how roles and expectations of adolescents, parents and healthcare professionals influence decision-making and to what extent this is considered in guidance. Aims: To identify recent empirical research on decision-making regarding care and treatment in adolescent cancer: (1) to synthesise evidence to define the role of adolescents, parents and healthcare professionals in the decision-making process and (2) to identify gaps in research. Design: A narrative systematic review of qualitative, quantitative and mixed-methods research. We adopted a textual approach to synthesis, using a theoretical framework of interactionism to interpret findings. Data Sources: The databases MEDLINE, PsycINFO, SCOPUS, EMBASE and CINHAL were searched from 2001 through May 2015 for publications on decision-making for adolescents (13–19 years) with cancer. Results: Twenty-eight articles were identified. Adolescents and parents initially find it difficult to participate in decision-making due to a lack of options in the face of protocol-driven care. Parent and adolescent preferences for information and response to loss of control vary between individuals and over time. No studies indicate parental or adolescent preference for a high degree of independence in decision-making. Conclusion: Striving to make parents and adolescents fully informed or urge them towards more independence than they prefer may add to distress and confusion. This may interfere with their ability to participate in their preferred way in decisions about care and treatment. Future research should include analysis of on-ground interactions among parents, adolescents and clinicians across the trajectory. PMID:27160700

Evolving neural networks for strategic decision-making problems.

PubMed

Kohl, Nate; Miikkulainen, Risto

2009-04-01

Evolution of neural networks, or neuroevolution, has been a successful approach to many low-level control problems such as pole balancing, vehicle control, and collision warning. However, certain types of problems-such as those involving strategic decision-making-have remained difficult for neuroevolution to solve. This paper evaluates the hypothesis that such problems are difficult because they are fractured: The correct action varies discontinuously as the agent moves from state to state. A method for measuring fracture using the concept of function variation is proposed and, based on this concept, two methods for dealing with fracture are examined: neurons with local receptive fields, and refinement based on a cascaded network architecture. Experiments in several benchmark domains are performed to evaluate how different levels of fracture affect the performance of neuroevolution methods, demonstrating that these two modifications improve performance significantly. These results form a promising starting point for expanding neuroevolution to strategic tasks.

"Something of the two of us". The emotionally loaded embryo disposition decision making of patients who view their embryo as a symbol of their relationship.

PubMed

Provoost, Veerle; Pennings, Guido; De Sutter, Petra; Dhont, Marc

2012-06-01

This paper describes a recently identified conception of the cryopreserved embryo as a symbol of one's relationship (SOR). A questionnaire was sent together with the embryo disposition decision (EDD) form to patients for whom embryos were cryopreserved at the department in Ghent, Belgium. We collected data on patient characteristics, their EDD attitudes and the reasons for their willingness or unwillingness to consider each of the disposition options (donation to others for reproduction, donation for science and discarding). The SOR view was found more often in patients who were less educated and whose last treatment was less than 3 years ago. Viewing the embryo as a SOR was not linked to more difficult decision making, but to more emotionally loaded decision making. In particular, patients with this view more often reported feelings of grief. This view was also linked to the outcome of the decision making process. The conception of the embryo as a SOR is part of an affective attitude towards embryos that has an impact on patients' disposition decisions. Alongside patients' values and principles, it is important that counselors acknowledge and clarify patients' affective conceptualizations.

Information and Decision-Making Needs Among People with Anxiety Disorders: Results of an Online Survey.

PubMed

Liebherz, Sarah; Härter, Martin; Dirmaier, Jörg; Tlach, Lisa

2015-12-01

People with anxiety disorders are faced with treatment decisions considerably affecting their life. Patient decision aids are aimed at enabling patients to deliberate treatment options based on individual values and to participate in medical decisions. This is the first study to determine patients' information and decision-making needs as a pre-requisite for the development of patient decision aids for anxiety disorders. An online cross-sectional survey was conducted between January and April 2013 on the e-health portal http://www.psychenet.de by using a self-administered questionnaire with items on internet use, online health information needs, role in decision making and important treatment decisions. Descriptive and inferential statistical as well as qualitative data analyses were performed. A total of 60 people with anxiety disorders with a mean age of 33.3 years (SD 10.5) participated in the survey. The most prevalent reasons for online health information search were the need for general information on anxiety disorders, the search for a physician or psychiatrist and the insufficiency of information given by the healthcare provider. Respondents experienced less shared and more autonomous decisions than they preferred. They assessed decisions on psychotherapy, medication, and treatment setting (inpatient or outpatient) as the most difficult decisions. Our results confirm the importance of offering patient decision aids for people with anxiety disorders that encourage patients to participate in decision making by providing information about the pros and cons of evidence-based treatment options.

Voices of African American, Caucasian, and Hispanic surrogates on the burdens of end-of-life decision making.

PubMed

Braun, Ursula K; Beyth, Rebecca J; Ford, Marvella E; McCullough, Laurence B

2008-03-01

End-of-life decisions are frequently made by patients' surrogates. Race and ethnicity may affect such decision making. Few studies have described how different racial/ethnic groups experience end-of-life surrogate decision making. To describe the self-reported experience the self-reported experience of African-American, Caucasian, and Hispanic surrogate decision makers of seriously ill patients and to examine the relationship of race, ethnicity, and culture to that experience. Purposive sample to include racial/ethnic minorities in a qualitative study using focus group interviews. The participants of the study were 44 experienced, mostly female, surrogate decision makers for older veterans. Transcripts were qualitatively analyzed to identify major themes, with particular attention to themes that might be unique to each of the three groups. The experience of burden of end-of-life decision making was similar in all three groups. This burden in its medical, personal, and familial dimensions is compounded by uncertainty about prognosis and the patient's preferences. Racial/ethnic variations of responses to this burden concerned the physician-family relationship, religion and faith, and past experiences with race/ethnicity concordant versus non-concordant physicians. Regardless of race/ethnicity, surrogates for seriously ill patients appeared to experience increased significant, multidimensional burdens of decision making under conditions of uncertainty about a patient's preferences. This aspect of the burden of surrogate decision making may not be fully appreciated by physicians. Physicians should identify and be especially attentive to strategies used by surrogates, which may vary by race/ethnicity, to reduce the uncertainty about a patient's preferences and thus the burden of surrogate decision making to assist them in this difficult process.

Ovarian tissue cryopreservation (OTC) in prepubertal girls and young women: an analysis of parents' and patients' decision-making.

PubMed

Sullivan-Pyke, Chantae S; Carlson, Claire A; Prewitt, Maureen; Gracia, Clarisa R; Ginsberg, Jill P

2018-04-01

The purpose of this study was to explore the decision-making influences, perceived level of control over decision-making, and mood states of parents and patients who were offered OTC prior to gonadotoxic therapy. Parents and patients, at least 12 years old, who required gonadotoxic therapy and were offered OTC prior to therapy, were asked to complete questionnaires. Two validated instruments were also used: the Decision-Making Control Instrument (DMCI) and the Profile of Mood States (POMS). The factors that influenced decision-making were compared using Student's t test, and the scores of DMCI and POMS were compared using the Mann-Whitney test. Thirty-six parents and 16 patients who elected ovarian tissue cryopreservation (OTC) completed questionnaires. Five parents who declined OTC also completed questionnaires. Accepters thought OTC was a good idea and that, in the future, science would enable cryopreserved ovarian tissue to be used to restore fertility (100% parents, 93.8% patients). Among accepters, the desire for genetically related children and prevention of the stress of infertility drove parents' and patients' decisions (90.9 and 100%, respectively). The desire to prevent the stress of infertility was important to parents, but patients were less likely to report that a desire to prevent the stress of infertility factored into their decision-making (66.7 vs. 50.0%; p < 0.001). All respondents felt in control of their decision and displayed low levels of mood disturbance. Though the decision to undergo experimental OTC is difficult and often urgent, this study suggests that families feel in control of their decision-making and report little emotional disturbance.

Army Reserve Components Research Roadmap Volume 2: Research Agenda

DTIC Science & Technology

1997-09-01

over a 150-mile radius. This obviously makes training above the company level difficult for any time other than annual training (AT). In addition...at a higher level of decision- making , fluidity in the assignments of force structures to units creates wide spread change which affects whole units...can increasingly make TADSS and other enhancements practical solutions to persistent training needs. It should also be noted that the questions

Taking a gamble or playing by the rules: Dissociable prefrontal systems implicated in probabilistic versus deterministic rule-based decisions

PubMed Central

Bhanji, Jamil P.; Beer, Jennifer S.; Bunge, Silvia A.

2014-01-01

A decision may be difficult because complex information processing is required to evaluate choices according to deterministic decision rules and/or because it is not certain which choice will lead to the best outcome in a probabilistic context. Factors that tax decision making such as decision rule complexity and low decision certainty should be disambiguated for a more complete understanding of the decision making process. Previous studies have examined the brain regions that are modulated by decision rule complexity or by decision certainty but have not examined these factors together in the context of a single task or study. In the present functional magnetic resonance imaging study, both decision rule complexity and decision certainty were varied in comparable decision tasks. Further, the level of certainty about which choice to make (choice certainty) was varied separately from certainty about the final outcome resulting from a choice (outcome certainty). Lateral prefrontal cortex, dorsal anterior cingulate cortex, and bilateral anterior insula were modulated by decision rule complexity. Anterior insula was engaged more strongly by low than high choice certainty decisions, whereas ventromedial prefrontal cortex showed the opposite pattern. These regions showed no effect of the independent manipulation of outcome certainty. The results disambiguate the influence of decision rule complexity, choice certainty, and outcome certainty on activity in diverse brain regions that have been implicated in decision making. Lateral prefrontal cortex plays a key role in implementing deterministic decision rules, ventromedial prefrontal cortex in probabilistic rules, and anterior insula in both. PMID:19781652

Measuring the involvement of people with HIV in treatment decision making using the control preferences scale.

PubMed

Kremer, Heidemarie; Ironson, Gail

2008-01-01

Since 1983, HIV patients have been advocating for participatory decision making. This study measures the involvement that HIV-positive people perceive in treatment decision making. A secondary objective is to assess the validity of the instrument used to examine decisional roles, the Control Preferences Scale (CPS). The authors interviewed 79 HIV-positive people, a sub-sample of a study on long survival with HIV, diverse with respect to ethnicity, age, gender, and sexual orientation. They compared the self- and researcher-rated decisional roles of participants on the CPS. They also assessed how well the CPS corresponds with Charles's paternalistic, shared- and informed-choice models of decision making about treatment based on decisional roles and information exchange. Most participants (75%) perceived collaborative/active involvement in decision making. Agreement (Kendall's tau-b) between self- and researcher-rated decisional roles on the CPS was 0.82, whereas agreement between self-ratings on the CPS and researcher ratings on Charles's classification was 0.60. Charles's classification was difficult if participants had chosen not to take their prescribed medication without being adequately informed about the risky consequences of this decision. In this study, HIV-positive people perceived a high level of involvement in decision making. Reliability and convergent validity of the CPS was high. Charles's classification was problematic because decisional roles and information exchange are distinct dimensions. Some people make risky treatment decisions on their own without being adequately informed. The CPS is a useful instrument to measure decisional role perceptions of HIV-positive people but needs to be complemented by an instrument measuring treatment knowledge.

Clinical decision making: how surgeons do it.

PubMed

Crebbin, Wendy; Beasley, Spencer W; Watters, David A K

2013-06-01

Clinical decision making is a core competency of surgical practice. It involves two distinct types of mental process best considered as the ends of a continuum, ranging from intuitive and subconscious to analytical and conscious. In practice, individual decisions are usually reached by a combination of each, according to the complexity of the situation and the experience/expertise of the surgeon. An expert moves effortlessly along this continuum, according to need, able to apply learned rules or algorithms to specific presentations, choosing these as a result of either pattern recognition or analytical thinking. The expert recognizes and responds quickly to any mismatch between what is observed and what was expected, coping with gaps in information and making decisions even where critical data may be uncertain or unknown. Even for experts, the cognitive processes involved are difficult to articulate as they tend to be very complex. However, if surgeons are to assist trainees in developing their decision-making skills, the processes need to be identified and defined, and the competency needs to be measurable. This paper examines the processes of clinical decision making in three contexts: making a decision about how to manage a patient; preparing for an operative procedure; and reviewing progress during an operative procedure. The models represented here are an exploration of the complexity of the processes, designed to assist surgeons understand how expert clinical decision making occurs and to highlight the challenge of teaching these skills to surgical trainees. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.

Challenges in shared decision making in advanced cancer care: a qualitative longitudinal observational and interview study.

PubMed

Brom, Linda; De Snoo-Trimp, Janine C; Onwuteaka-Philipsen, Bregje D; Widdershoven, Guy A M; Stiggelbout, Anne M; Pasman, H Roeline W

2017-02-01

Patients' preferences and expectations should be taken into account in treatment decision making in the last phase of life. Shared decision making (SDM) is regarded as a way to give the patient a central role in decision making. Little is known about how SDM is used in clinical practice in advanced cancer care. To examine whether and how the steps of SDM can be recognized in decision making about second- and third-line chemotherapy. Fourteen advanced cancer patients were followed over time using face-to-face in-depth interviews and observations of the patients' out-clinic visits. Interviews and outpatient clinic visits in which treatment options were discussed or decisions made were transcribed verbatim and analysed using open coding. Patients were satisfied with the decision-making process, but the steps of SDM were barely seen in daily practice. The creation of awareness about available treatment options by physicians was limited and not discussed in an equal way. Patients' wishes and concerns were not explicitly assessed, which led to different expectations about improved survival from subsequent lines of chemotherapy. To reach SDM in daily practice, physicians should create awareness of all treatment options, including forgoing treatment, and communicate the risk of benefit and harm. Open and honest communication is needed in which patients' expectations and concerns are discussed. Through this, the difficult process of decision making in the last phase of life can be facilitated and the focus on the best care for the specific patient is strengthened. © 2015 The Authors. Health Expectations Published by John Wiley & Sons Ltd.

Initiating decision-making conversations in palliative care: an ethnographic discourse analysis.

PubMed

Bélanger, Emmanuelle; Rodríguez, Charo; Groleau, Danielle; Légaré, France; Macdonald, Mary Ellen; Marchand, Robert

2014-01-01

Conversations about end-of-life care remain challenging for health care providers. The tendency to delay conversations about care options represents a barrier that impedes the ability of terminally-ill patients to participate in decision-making. Family physicians with a palliative care practice are often responsible for discussing end-of-life care preferences with patients, yet there is a paucity of research directly observing these interactions. In this study, we sought to explore how patients and family physicians initiated decision-making conversations in the context of a community hospital-based palliative care service. This qualitative study combined discourse analysis with ethnographic methods. The field research lasted one year, and data were generated through participant observation and audio-recordings of consultations. A total of 101 consultations were observed longitudinally between 18 patients, 6 family physicians and 2 pivot nurses. Data analysis consisted in exploring the different types of discourses initiating decision-making conversations and how these discourses were affected by the organizational context in which they took place. The organization of care had an impact on decision-making conversations. The timing and origin of referrals to palliative care shaped whether patients were still able to participate in decision-making, and the decisions that remained to be made. The type of decisions to be made also shaped how conversations were initiated. Family physicians introduced decision-making conversations about issues needing immediate attention, such as symptom management, by directly addressing or eliciting patients' complaints. When decisions involved discussing impending death, decision-making conversations were initiated either indirectly, by prompting the patients to express their understanding of the disease and its progression, or directly, by providing a justification for broaching a difficult topic. Decision-making conversations and the initiation thereof were framed by the organization of care and the referral process prior to initial encounters. While symptom management was taken for granted as part of health care professionals' expected role, engaging in decisions regarding preparation for death implicitly remained under patients' control. This work makes important clinical contributions by exposing the rhetorical function of family physicians' discourse when introducing palliative care decisions.

The value of artefacts in stimulated-recall interviews.

PubMed

Burden, Sarah; Topping, Annie; O'Halloran, Catherine

2015-09-01

To assess the use of artefacts in semi-structured, stimulated-recall interviews in a study exploring mentors' decisions regarding students' competence in practice. Few empirical studies have examined how mentors reach a decision when assessing students' performance in practice. Concerns have repeatedly been voiced that students may lack essential skills at the point of registration or that mentors may have failed or been reticent to judge students' performance as unsatisfactory. Student practice assessment documents (PADs) were used in stimulated-recall (SR) interviews with mentors to explore decision making. A review of the literature identified that artefacts can play a role in triggering a more comprehensive retrospective examination of decision making, thus helping to capture the essence of a mentor's decision over time and in context. Use of an artefact to stimulate recall can elicit evidence of thought processes, which may be difficult to obtain in a normal, semi-structured interview. PADs proved to be a valuable way to generate naturalistic decision making. In addition, discussion of artefacts created by participants can promote participant-driven enquiry, thereby reducing researcher bias. Identifying an approach that captures post hoc decision making based on sustained engagement and interaction between students and their mentors was a challenge. Artefacts can be used to address the difficulties associated with retrospective introspection about a unique decision. There is the potential to increase the use of artefacts in healthcare research. SR can also help novice mentors develop their skills in making decisions regarding assessments of students.

Patchy 'coherence': using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC).

PubMed

Lloyd, Amy; Joseph-Williams, Natalie; Edwards, Adrian; Rix, Andrew; Elwyn, Glyn

2013-09-05

Implementing shared decision making into routine practice is proving difficult, despite considerable interest from policy-makers, and is far more complex than merely making decision support interventions available to patients. Few have reported successful implementation beyond research studies. MAking Good Decisions In Collaboration (MAGIC) is a multi-faceted implementation program, commissioned by The Health Foundation (UK), to examine how best to put shared decision making into routine practice. In this paper, we investigate healthcare professionals' perspectives on implementing shared decision making during the MAGIC program, to examine the work required to implement shared decision making and to inform future efforts. The MAGIC program approached implementation of shared decision making by initiating a range of interventions including: providing workshops; facilitating development of brief decision support tools (Option Grids); initiating a patient activation campaign ('Ask 3 Questions'); gathering feedback using Decision Quality Measures; providing clinical leads meetings, learning events, and feedback sessions; and obtaining executive board level support. At 9 and 15 months (May and November 2011), two rounds of semi-structured interviews were conducted with healthcare professionals in three secondary care teams to explore views on the impact of these interventions. Interview data were coded by two reviewers using a framework derived from the Normalization Process Theory. A total of 54 interviews were completed with 31 healthcare professionals. Partial implementation of shared decision making could be explained using the four components of the Normalization Process Theory: 'coherence,' 'cognitive participation,' 'collective action,' and 'reflexive monitoring.' Shared decision making was integrated into routine practice when clinical teams shared coherent views of role and purpose ('coherence'). Shared decision making was facilitated when teams engaged in developing and delivering interventions ('cognitive participation'), and when those interventions fit with existing skill sets and organizational priorities ('collective action') resulting in demonstrable improvements to practice ('reflexive monitoring'). The implementation process uncovered diverse and conflicting attitudes toward shared decision making; 'coherence' was often missing. The study showed that implementation of shared decision making is more complex than the delivery of patient decision support interventions to patients, a portrayal that often goes unquestioned. Normalizing shared decision making requires intensive work to ensure teams have a shared understanding of the purpose of involving patients in decisions, and undergo the attitudinal shifts that many health professionals feel are required when comprehension goes beyond initial interpretations. Divergent views on the value of engaging patients in decisions remain a significant barrier to implementation.

Patchy ‘coherence’: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC)

PubMed Central

2013-01-01

Background Implementing shared decision making into routine practice is proving difficult, despite considerable interest from policy-makers, and is far more complex than merely making decision support interventions available to patients. Few have reported successful implementation beyond research studies. MAking Good Decisions In Collaboration (MAGIC) is a multi-faceted implementation program, commissioned by The Health Foundation (UK), to examine how best to put shared decision making into routine practice. In this paper, we investigate healthcare professionals’ perspectives on implementing shared decision making during the MAGIC program, to examine the work required to implement shared decision making and to inform future efforts. Methods The MAGIC program approached implementation of shared decision making by initiating a range of interventions including: providing workshops; facilitating development of brief decision support tools (Option Grids); initiating a patient activation campaign (‘Ask 3 Questions’); gathering feedback using Decision Quality Measures; providing clinical leads meetings, learning events, and feedback sessions; and obtaining executive board level support. At 9 and 15 months (May and November 2011), two rounds of semi-structured interviews were conducted with healthcare professionals in three secondary care teams to explore views on the impact of these interventions. Interview data were coded by two reviewers using a framework derived from the Normalization Process Theory. Results A total of 54 interviews were completed with 31 healthcare professionals. Partial implementation of shared decision making could be explained using the four components of the Normalization Process Theory: ‘coherence,’ ‘cognitive participation,’ ‘collective action,’ and ‘reflexive monitoring.’ Shared decision making was integrated into routine practice when clinical teams shared coherent views of role and purpose (‘coherence’). Shared decision making was facilitated when teams engaged in developing and delivering interventions (‘cognitive participation’), and when those interventions fit with existing skill sets and organizational priorities (‘collective action’) resulting in demonstrable improvements to practice (‘reflexive monitoring’). The implementation process uncovered diverse and conflicting attitudes toward shared decision making; ‘coherence’ was often missing. Conclusions The study showed that implementation of shared decision making is more complex than the delivery of patient decision support interventions to patients, a portrayal that often goes unquestioned. Normalizing shared decision making requires intensive work to ensure teams have a shared understanding of the purpose of involving patients in decisions, and undergo the attitudinal shifts that many health professionals feel are required when comprehension goes beyond initial interpretations. Divergent views on the value of engaging patients in decisions remain a significant barrier to implementation. PMID:24006959

Discrete event simulation for healthcare organizations: a tool for decision making.

PubMed

Hamrock, Eric; Paige, Kerrie; Parks, Jennifer; Scheulen, James; Levin, Scott

2013-01-01

Healthcare organizations face challenges in efficiently accommodating increased patient demand with limited resources and capacity. The modern reimbursement environment prioritizes the maximization of operational efficiency and the reduction of unnecessary costs (i.e., waste) while maintaining or improving quality. As healthcare organizations adapt, significant pressures are placed on leaders to make difficult operational and budgetary decisions. In lieu of hard data, decision makers often base these decisions on subjective information. Discrete event simulation (DES), a computerized method of imitating the operation of a real-world system (e.g., healthcare delivery facility) over time, can provide decision makers with an evidence-based tool to develop and objectively vet operational solutions prior to implementation. DES in healthcare commonly focuses on (1) improving patient flow, (2) managing bed capacity, (3) scheduling staff, (4) managing patient admission and scheduling procedures, and (5) using ancillary resources (e.g., labs, pharmacies). This article describes applicable scenarios, outlines DES concepts, and describes the steps required for development. An original DES model developed to examine crowding and patient flow for staffing decision making at an urban academic emergency department serves as a practical example.

Perspectives of decision-making in requests for euthanasia: a qualitative research among patients, relatives and treating physicians in the Netherlands.

PubMed

Dees, Marianne K; Vernooij-Dassen, Myrra J; Dekkers, Wim J; Elwyn, Glyn; Vissers, Kris C; van Weel, Chris

2013-01-01

Euthanasia has been legally performed in the Netherlands since 2002. Respect for patient's autonomy is the underpinning ethical principal. However, patients have no right to euthanasia, and physicians have no obligation to provide it. Although over 3000 cases are conducted per year in the Netherlands, there is little known about how decision-making occurs and no guidance to support this difficult aspect of clinical practice. To explore the decision-making process in cases where patients request euthanasia and understand the different themes relevant to optimise this decision-making process. A qualitative thematic analysis of interviews with patients making explicit requests for euthanasia, most-involved relative(s) and treating physician. Thirty-two cases, 31 relatives and 28 treating physicians. Settings were patients' and relatives' homes and physicians' offices. Five main themes emerged: (1) initiation of sharing views and values about euthanasia, (2) building relationships as part of the negotiation, (3) fulfilling legal requirements, (4) detailed work of preparing and performing euthanasia and (5) aftercare and closing. A patient's request for euthanasia entails a complex process that demands emotional work by all participants. It is characterised by an intensive period of sharing information, relationship building and negotiation in order to reach agreement. We hypothesise that making decisions about euthanasia demands a proactive approach towards participants' preferences and values regarding end of life, towards the needs of relatives, towards the burden placed on physicians and a careful attention to shared decision-making. Future research should address the communicational skills professionals require for such complex decision-making.

The use of a multidimensional space for fusion candidate representation in a maritime domain awareness application

NASA Astrophysics Data System (ADS)

Lefebvre, Eric; Helleur, Christopher; Kashyap, Nathan

2008-03-01

Maritime surveillance of coastal regions requires operational staff to integrate a large amount of information from a variety of military and civilian sources. The diverse nature of the information sources makes complete automation difficult. The volume of vessels tracked and the number of sources makes it difficult for the limited operation centre staff to fuse all the information manually within a reasonable timeframe. In this paper, a conceptual decision space is proposed to provide a framework for automating the process of operators integrating the sources needed to maintain Maritime Domain Awareness. The decision space contains all potential pairs of ship tracks that are candidates for fusion. The location of the candidate pairs in this defined space depends on the value of the parameters used to make a decision. In the application presented, three independent parameters are used: the source detection efficiency, the geo-feasibility, and the track quality. One of three decisions is applied to each candidate track pair based on these three parameters: 1. to accept the fusion, in which case tracks are fused in one track, 2. to reject the fusion, in which case the candidate track pair is removed from the list of potential fusion, and 3. to defer the fusion, in which case no fusion occurs but the candidate track pair remains in the list of potential fusion until sufficient information is provided. This paper demonstrates in an operational setting how a proposed conceptual space is used to optimize the different thresholds for automatic fusion decision while minimizing the list of unresolved cases when the decision is left to the operator.

Decision aids to increase living donor kidney transplantation

PubMed Central

Gander, Jennifer C.; Gordon, Elisa J.; Patzer, Rachel E.

2017-01-01

Purpose of review For the more than 636,000 adults with end-stage renal disease (ESRD) in the U.S., kidney transplantation is the preferred treatment compared to dialysis. Living donor kidney transplantation (LDKT) comprised 31% of kidney transplantations in 2015, an 8% decrease since 2004. We aimed to summarize the current literature on decision aids that could be used to improve LDKT rates. Recent findings Decision aids are evidence-based tools designed to help patients and their families make difficult treatment decisions. LDKT decision aids can help ESRD patients, patients’ family and friends, and healthcare providers engage in treatment decisions and thereby overcome multifactorial LDKT barriers. Summary We identified 12 LDKT decision aids designed to provide information about LDKT, and/or to help ESRD patients identify potential living donors, and/or to help healthcare providers make decisions about treatment for ESRD or living donation. Of these, 4 were shown to be effective in increasing LDKT, donor inquiries, LDKT knowledge, and willingness to discuss LDKT. Although each LDKT decision aid has limitations, adherence to decision aid development guidelines may improve decision aid utilization and access to LDKT. PMID:29034143

Clarifying values: an updated review

PubMed Central

2013-01-01

Background Consensus guidelines have recommended that decision aids include a process for helping patients clarify their values. We sought to examine the theoretical and empirical evidence related to the use of values clarification methods in patient decision aids. Methods Building on the International Patient Decision Aid Standards (IPDAS) Collaboration’s 2005 review of values clarification methods in decision aids, we convened a multi-disciplinary expert group to examine key definitions, decision-making process theories, and empirical evidence about the effects of values clarification methods in decision aids. To summarize the current state of theory and evidence about the role of values clarification methods in decision aids, we undertook a process of evidence review and summary. Results Values clarification methods (VCMs) are best defined as methods to help patients think about the desirability of options or attributes of options within a specific decision context, in order to identify which option he/she prefers. Several decision making process theories were identified that can inform the design of values clarification methods, but no single “best” practice for how such methods should be constructed was determined. Our evidence review found that existing VCMs were used for a variety of different decisions, rarely referenced underlying theory for their design, but generally were well described in regard to their development process. Listing the pros and cons of a decision was the most common method used. The 13 trials that compared decision support with or without VCMs reached mixed results: some found that VCMs improved some decision-making processes, while others found no effect. Conclusions Values clarification methods may improve decision-making processes and potentially more distal outcomes. However, the small number of evaluations of VCMs and, where evaluations exist, the heterogeneity in outcome measures makes it difficult to determine their overall effectiveness or the specific characteristics that increase effectiveness. PMID:24625261

Measuring shared decision making in the consultation: a comparison of the OPTION and Informed Decision Making instruments.

PubMed

Weiss, Marjorie C; Peters, Tim J

2008-01-01

To investigate the applied and conceptual relationship between two measures of shared decision making using the OPTION instrument developed in Wales and the Informed Decision Making instrument developed in Seattle, USA using audio-taped consultation data from a UK general practice population. Twelve general practitioners were recruited from 6 general practices in the southwest of England. One hundred twenty-three GP-patient consultations were audio-recorded. Audiotapes were sent off to, and rated by, respective experts in the use of the OPTION and the Informed Decision Making instruments. Compared to earlier work using the Informed Decision Making tool, consultations in this sample were shorter, had fewer decisions and tended to have a greater number of elements present. Similar to previous research using the OPTION, values using the OPTION instrument were low with two items, giving the patient opportunities to ask questions and checking patient understanding, exhibiting the most variability. Using a 'key' decision in each consultation as the basis for comparison, the Informed Decision Making score was not related to the overall OPTION score (Spearman's rho=0.14, p=0.13). Both instruments also predicted different 'best' and 'worst' doctors. Using a Bland-Altman plot for assessing agreement, the mean difference between the two measures was 1.11 (CI 0.66-1.56) and the limits of agreement were -3.94 to 6.16. There were several elements between the two instruments that appeared conceptually similar and correlations for these were generally higher. These were: discussing alternatives or options (Spearman's rho=0.35, p=0.0001), discussion of the patient's role in decision making (Spearman's rho=0.23, p=0.012), discussion of the pros/cons of the alternatives (Spearman's rho=0.20, p=0.024) and assessment of the patient's understanding (Spearman's rho=0.19, p=0.03). Measures of shared decision making are helpful in identifying those shared decision making skills which may be problematic or difficult to integrate into practice and provide a tool by which the development of skills can be assessed over time. Research may implicitly place undue value on those aspects of shared decision making which are most easily measured. Shared decision making tools are a useful way of capturing the presence or absence of specific shared decision making skills and changes in skills acquisition over time. However there may be limits in the extent to which the concept of shared decision making can be measured and that more easily measured skills will be emphasised to the detriment of other important shared decision making skills.

Virtual Human Role Players for Studying Social Factors in Organizational Decision Making

PubMed Central

Khooshabeh, Peter; Lucas, Gale

2018-01-01

The cyber domain of military operations presents many challenges. A unique element is the social dynamic between cyber operators and their leadership because of the novel subject matter expertise involved in conducting technical cyber tasks, so there will be situations where senior leaders might have much less domain knowledge or no experience at all relative to the warfighters who report to them. Nonetheless, it will be important for junior cyber operators to convey convincing information relevant to a mission in order to persuade or influence a leader to make informed decisions. The power dynamic will make it difficult for the junior cyber operator to successfully influence a higher ranking leader. Here we present a perspective with a sketch for research paradigm(s) to study how different factors (normative vs. informational social influence, degree of transparency, and perceived appropriateness of making suggestions) might interact with differential social power dynamics of individuals in cyber decision-making contexts. Finally, we contextualize this theoretical perspective for the research paradigms in viable training technologies. PMID:29545759

Exploring differences in the use of the statin choice decision aid and diabetes medication choice decision aid in primary care.

PubMed

Ballard, Aimee Yu; Kessler, Maya; Scheitel, Marianne; Montori, Victor M; Chaudhry, Rajeev

2017-08-10

Shared decision making is essential to patient centered care, but can be difficult for busy clinicians to implement into practice. Tools have been developed to aid in shared decision making and embedded in electronic medical records (EMRs) to facilitate use. This study was undertaken to explore the patterns of use and barriers and facilitators to use of two decision aids, the Statin Choice Decision Aid (SCDA) and the Diabetes Medication Choice Decision Aid (DMCDA), in primary care practices where the decision aids are embedded in the EMR. A survey exploring factors that influenced use of each decision aid was sent to eligible primary care clinicians affiliated with the Mayo Clinic in Rochester, MN. Survey data was collected and clinician use of each decision aid via links from the EMR was tracked. The survey response rate was 40% (105/262). Log file data indicated 51% of clinicians used the SCDA and 9% of clinicians used the DMCDA. Reasons for lack of use included lack of knowledge of the EMR link, not finding the decision aids helpful, and time constraints. Survey responses indicated that use of the tool as intended was low, with many clinicians only discussing decision aid topics that they found relevant. Although guidelines for both the treatment of blood cholesterol with a statin and for the treatment of hyperglycemia in type 2 diabetes recommend shared decision making, tools that facilitate shared decision making are not routinely used even when embedded in the EMR. Even when decision aids are used, their use may not reflect patient centered care.

Specializations for reward-guided decision-making in the primate ventral prefrontal cortex.

PubMed

Murray, Elisabeth A; Rudebeck, Peter H

2018-05-23

The estimated values of choices, and therefore decision-making based on those values, are influenced by both the chance that the chosen items or goods can be obtained (availability) and their current worth (desirability) as well as by the ability to link the estimated values to choices (a process sometimes called credit assignment). In primates, the prefrontal cortex (PFC) has been thought to contribute to each of these processes; however, causal relationships between particular subdivisions of the PFC and specific functions have been difficult to establish. Recent lesion-based research studies have defined the roles of two different parts of the primate PFC - the orbitofrontal cortex (OFC) and the ventral lateral frontal cortex (VLFC) - and their subdivisions in evaluating each of these factors and in mediating credit assignment during reward-based decision-making.

Uncertainty Categorization, Modeling, and Management for Regional Water Supply Planning

NASA Astrophysics Data System (ADS)

Fletcher, S.; Strzepek, K. M.; AlSaati, A.; Alhassan, A.

2016-12-01

Many water planners face increased pressure on water supply systems from growing demands, variability in supply and a changing climate. Short-term variation in water availability and demand; long-term uncertainty in climate, groundwater storage, and sectoral competition for water; and varying stakeholder perspectives on the impacts of water shortages make it difficult to assess the necessity of expensive infrastructure investments. We categorize these uncertainties on two dimensions: whether they are the result of stochastic variation or epistemic uncertainty, and whether the uncertainties can be described probabilistically or are deep uncertainties whose likelihood is unknown. We develop a decision framework that combines simulation for probabilistic uncertainty, sensitivity analysis for deep uncertainty and Bayesian decision analysis for uncertainties that are reduced over time with additional information. We apply this framework to two contrasting case studies - drought preparedness in Melbourne, Australia and fossil groundwater depletion in Riyadh, Saudi Arabia - to assess the impacts of different types of uncertainty on infrastructure decisions. Melbourne's water supply system relies on surface water, which is impacted by natural variation in rainfall, and a market-based system for managing water rights. Our results show that small, flexible investment increases can mitigate shortage risk considerably at reduced cost. Riyadh, by contrast, relies primarily on desalination for municipal use and fossil groundwater for agriculture, and a centralized planner makes allocation decisions. Poor regional groundwater measurement makes it difficult to know when groundwater pumping will become uneconomical, resulting in epistemic uncertainty. However, collecting more data can reduce the uncertainty, suggesting the need for different uncertainty modeling and management strategies in Riyadh than in Melbourne. We will categorize the two systems and propose appropriate decision making under uncertainty methods from the state of the art. We will compare the efficiency of alternative approaches to the two case studies. Finally, we will present a hybrid decision analytic tool to address the synthesis of uncertainties.

Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgment and signal detection analysis

PubMed Central

2012-01-01

Background The importance of respecting women’s wishes to give birth close to their local community is supported by policy in many developed countries. However, persistent concerns about the quality and safety of maternity care in rural communities have been expressed. Safe childbirth in rural communities depends on good risk assessment and decision making as to whether and when the transfer of a woman in labour to an obstetric led unit is required. This is a difficult decision. Wide variation in transfer rates between rural maternity units have been reported suggesting different decision making criteria may be involved; furthermore, rural midwives and family doctors report feeling isolated in making these decisions and that staff in urban centres do not understand the difficulties they face. In order to develop more evidence based decision making strategies greater understanding of the way in which maternity care providers currently make decisions is required. This study aimed to examine how midwives working in urban and rural settings and obstetricians make intrapartum transfer decisions, and describe sources of variation in decision making. Methods The study was conducted in three stages. 1. 20 midwives and four obstetricians described factors influencing transfer decisions. 2. Vignettes depicting an intrapartum scenario were developed based on stage one data. 3. Vignettes were presented to 122 midwives and 12 obstetricians who were asked to assess the level of risk in each case and decide whether to transfer or not. Social judgment analysis was used to identify the factors and factor weights used in assessment. Signal detection analysis was used to identify participants’ ability to distinguish high and low risk cases and personal decision thresholds. Results When reviewing the same case information in vignettes midwives in different settings and obstetricians made very similar risk assessments. Despite this, a wide range of transfer decisions were still made, suggesting that the main source of variation in decision making and transfer rates is not in the assessment but the personal decision thresholds of clinicians. Conclusions Currently health care practice focuses on supporting or improving decision making through skills training and clinical guidelines. However, these methods alone are unlikely to be effective in improving consistency of decision making. PMID:23114289

Patients’ Non-Medical Characteristics Contribute to Collective Medical Decision-Making at Multidisciplinary Oncological Team Meetings

PubMed Central

Restivo, Léa; Apostolidis, Thémis; Bouhnik, Anne-Déborah; Garciaz, Sylvain; Aurran, Thérèse; Julian-Reynier, Claire

2016-01-01

Background The contribution of patients’ non-medical characteristics to individual physicians’ decision-making has attracted considerable attention, but little information is available on this topic in the context of collective decision-making. Medical decision-making at cancer centres is currently carried out using a collective approach, at MultiDisciplinary Team (MDT) meetings. The aim of this study was to determine how patients’ non-medical characteristics are presented at MDT meetings and how this information may affect the team’s final medical decisions. Design Observations were conducted at a French Cancer Centre during MDT meetings at which non-standard cases involving some uncertainty were discussed from March to May 2014. Physicians’ verbal statements and predefined contextual parameters were collected with a non-participant observational approach. Non numerical data collected in the form of open notes were then coded for quantitative analysis. Univariate and multivariate statistical analyses were performed. Results In the final sample of patients’ records included and discussed (N = 290), non-medical characteristics were mentioned in 32.8% (n = 95) of the cases. These characteristics corresponded to demographics in 22.8% (n = 66) of the cases, psychological data in 11.7% (n = 34), and relational data in 6.2% (n = 18). The patient’s age and his/her “likeability” were the most frequently mentioned characteristics. In 17.9% of the cases discussed, the final decision was deferred: this outcome was positively associated with the patients’ non-medical characteristics and with uncertainty about the outcome of the therapeutic options available. Limitations The design of the study made it difficult to draw definite cause-and-effect conclusions. Conclusion The Social Representations approach suggests that patients’ non-medical characteristics constitute a kind of tacit professional knowledge that may be frequently mobilised in physicians’ everyday professional practice. The links observed between patients’ attributes and the medical decisions made at these meetings show that these attributes should be taken into account in order to understand how medical decisions are reached in difficult situations of this kind. PMID:27167521

Success matters: Recasting the relationship among geophysical, biological, and behavioral scientists to support decision making on major environmental challenges

NASA Astrophysics Data System (ADS)

Knopman, Debra S.

2006-03-01

Coping with global change, providing clean water for growing populations, and disposing of nuclear waste are some of the most difficult public policy challenges of our time. Unknowns in the physical sciences are one source of the difficulty. Real difficulties in meeting these challenges also arise in the behavioral sciences. A potentially rich vein of transdisciplinary research is to integrate the psychology of decision making, known as "judgment and decision making," or JDM, with the development of technical information and decision support tools for complex, long-term environmental problems. Practitioners of JDM conduct research on how individuals and groups respond to uncertainty and ambiguity, hedge against risks, anchor decisions to the status quo, compare relative risks and rewards of alternative strategies, and cope with other classes of decisions. Practitioners use a variety of stimuli, chance devices, hypothetical and real choices involving small stakes, scenarios, and questionnaires to measure (directly and indirectly) preferences under varying conditions. These kinds of experiments can help guide choices about the level of complexity required for different types of decision-making processes, the value of new data collection efforts, and the ways in which uncertainty in model outcomes can be cast to minimize decision-making paralysis. They can also provide a scientific basis for interacting with decision makers throughout the model development process, designing better ways of eliciting and combining opinions and of communicating information relevant to public policy issues with the goal of improving the value of the scientific contribution to the social decision.

Consumer decision making in the individual health insurance market.

PubMed

Marquis, M Susan; Buntin, Melinda Beeuwkes; Escarce, José J; Kapur, Kanika; Louis, Thomas A; Yegian, Jill M

2006-01-01

This paper summarizes the results from a study of consumer decision making in California's individual health insurance market. We conclude that price subsidies will have only modest effects on participation and that efforts to reduce nonprice barriers might be just as effective. We also find that there is substantial pooling in the individual market and that it increases over time because people who become sick can continue coverage without new underwriting. Finally, we show that people prefer more-generous benefits and that it is difficult to induce people in poor health to enroll in high-deductible health plans.

"Best Case/Worst Case": Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-Moment Surgical Decisions.

PubMed

Kruser, Jacqueline M; Nabozny, Michael J; Steffens, Nicole M; Brasel, Karen J; Campbell, Toby C; Gaines, Martha E; Schwarze, Margaret L

2015-09-01

To evaluate a communication tool called "Best Case/Worst Case" (BC/WC) based on an established conceptual model of shared decision-making. Focus group study. Older adults (four focus groups) and surgeons (two focus groups) using modified questions from the Decision Aid Acceptability Scale and the Decisional Conflict Scale to evaluate and revise the communication tool. Individuals aged 60 and older recruited from senior centers (n = 37) and surgeons from academic and private practices in Wisconsin (n = 17). Qualitative content analysis was used to explore themes and concepts that focus group respondents identified. Seniors and surgeons praised the tool for the unambiguous illustration of multiple treatment options and the clarity gained from presentation of an array of treatment outcomes. Participants noted that the tool provides an opportunity for in-the-moment, preference-based deliberation about options and a platform for further discussion with other clinicians and loved ones. Older adults worried that the format of the tool was not universally accessible for people with different educational backgrounds, and surgeons had concerns that the tool was vulnerable to physicians' subjective biases. The BC/WC tool is a novel decision support intervention that may help facilitate difficult decision-making for older adults and their physicians when considering invasive, acute medical treatments such as surgery. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

Emotions, decisions, and the limits of rationality: symposium introduction.

PubMed

Ubel, Peter A

2005-01-01

In this symposium, three speakers describe research that examines ways in which people's decision-making is affected by emotions. In his paper, Dr. Loewenstein describes research on the properties and effects of "projection bias," the tendency to allow one's immediate, often transient, preferences to influence decisions in the future when one's preferences will be predictable different. Over-shopping on an empty stomach or failing, when not addicted, to appreciate one's future helplessness in the face of drug craving, are examples. Dr. Schwarz focuses on how experiences that accompany the thought process can influence the ease of access to information or the fluency with which new information can be processed. These meta-cognitive experiences can affect decisions. For example, recalling many risk-increasing behaviors is more difficult than recalling only a few. Drawing on this difficulty, people who recall many risk-increasing behaviors infer that they are at lower risk than people who recall merely a few risk-increasing behaviors, in contrast to what the content of recall would suggest. Finally, Dr. Bodenhausen clarifies what is meant by stereotyping, considers how stereotypes might influence decision-making processes, and discuss why this influence often might not be very desirable. He then describes research about factors that amplify the biasing impact of stereotypes in decision making processes. The authors provide examples, discuss implications of their findings for medical decision-making, and describe strategies that we might employ to minimize or eliminate the biases that might be introduced into decision-making processes.

A Decision Support System for effective use of probability forecasts

NASA Astrophysics Data System (ADS)

De Kleermaeker, Simone; Verkade, Jan

2013-04-01

Often, water management decisions are based on hydrological forecasts. These forecasts, however, are affected by inherent uncertainties. It is increasingly common for forecasting agencies to make explicit estimates of these uncertainties and thus produce probabilistic forecasts. Associated benefits include the decision makers' increased awareness of forecasting uncertainties and the potential for risk-based decision-making. Also, a stricter separation of responsibilities between forecasters and decision maker can be made. However, simply having probabilistic forecasts available is not sufficient to realise the associated benefits. Additional effort is required in areas such as forecast visualisation and communication, decision making in uncertainty and forecast verification. Also, revised separation of responsibilities requires a shift in institutional arrangements and responsibilities. A recent study identified a number of additional issues related to the effective use of probability forecasts. When moving from deterministic to probability forecasting, a dimension is added to an already multi-dimensional problem; this makes it increasingly difficult for forecast users to extract relevant information from a forecast. A second issue is that while probability forecasts provide a necessary ingredient for risk-based decision making, other ingredients may not be present. For example, in many cases no estimates of flood damage, of costs of management measures and of damage reduction are available. This paper presents the results of the study, including some suggestions for resolving these issues and the integration of those solutions in a prototype decision support system (DSS). A pathway for further development of the DSS is outlined.

Characterizing uncertain sea-level rise projections to support investment decisions.

PubMed

Sriver, Ryan L; Lempert, Robert J; Wikman-Svahn, Per; Keller, Klaus

2018-01-01

Many institutions worldwide are considering how to include uncertainty about future changes in sea-levels and storm surges into their investment decisions regarding large capital infrastructures. Here we examine how to characterize deeply uncertain climate change projections to support such decisions using Robust Decision Making analysis. We address questions regarding how to confront the potential for future changes in low probability but large impact flooding events due to changes in sea-levels and storm surges. Such extreme events can affect investments in infrastructure but have proved difficult to consider in such decisions because of the deep uncertainty surrounding them. This study utilizes Robust Decision Making methods to address two questions applied to investment decisions at the Port of Los Angeles: (1) Under what future conditions would a Port of Los Angeles decision to harden its facilities against extreme flood scenarios at the next upgrade pass a cost-benefit test, and (2) Do sea-level rise projections and other information suggest such conditions are sufficiently likely to justify such an investment? We also compare and contrast the Robust Decision Making methods with a full probabilistic analysis. These two analysis frameworks result in similar investment recommendations for different idealized future sea-level projections, but provide different information to decision makers and envision different types of engagement with stakeholders. In particular, the full probabilistic analysis begins by aggregating the best scientific information into a single set of joint probability distributions, while the Robust Decision Making analysis identifies scenarios where a decision to invest in near-term response to extreme sea-level rise passes a cost-benefit test, and then assembles scientific information of differing levels of confidence to help decision makers judge whether or not these scenarios are sufficiently likely to justify making such investments. Results highlight the highly-localized and context dependent nature of applying Robust Decision Making methods to inform investment decisions.

Characterizing uncertain sea-level rise projections to support investment decisions

PubMed Central

Lempert, Robert J.; Wikman-Svahn, Per; Keller, Klaus

2018-01-01

Many institutions worldwide are considering how to include uncertainty about future changes in sea-levels and storm surges into their investment decisions regarding large capital infrastructures. Here we examine how to characterize deeply uncertain climate change projections to support such decisions using Robust Decision Making analysis. We address questions regarding how to confront the potential for future changes in low probability but large impact flooding events due to changes in sea-levels and storm surges. Such extreme events can affect investments in infrastructure but have proved difficult to consider in such decisions because of the deep uncertainty surrounding them. This study utilizes Robust Decision Making methods to address two questions applied to investment decisions at the Port of Los Angeles: (1) Under what future conditions would a Port of Los Angeles decision to harden its facilities against extreme flood scenarios at the next upgrade pass a cost-benefit test, and (2) Do sea-level rise projections and other information suggest such conditions are sufficiently likely to justify such an investment? We also compare and contrast the Robust Decision Making methods with a full probabilistic analysis. These two analysis frameworks result in similar investment recommendations for different idealized future sea-level projections, but provide different information to decision makers and envision different types of engagement with stakeholders. In particular, the full probabilistic analysis begins by aggregating the best scientific information into a single set of joint probability distributions, while the Robust Decision Making analysis identifies scenarios where a decision to invest in near-term response to extreme sea-level rise passes a cost-benefit test, and then assembles scientific information of differing levels of confidence to help decision makers judge whether or not these scenarios are sufficiently likely to justify making such investments. Results highlight the highly-localized and context dependent nature of applying Robust Decision Making methods to inform investment decisions. PMID:29414978

[Issues related to consent to healthcare decisions in children and adolescents].

PubMed

Bailly, D

2010-02-01

The process of consent to healthcare decisions in children and adolescents often set physicians difficult problems. From what age is a child able to understand the information given to him or her about illness and treatment? Is an ill child indeed in the capacity to give his or her voluntary consent to treatment? How to define and to assess the capacity of an ill child to take part in treatment decisions? More than the age of the child, it is his or her level of cognitive, emotional and social development and its interactions with illness that will determine his or her degree of involvement in the decision-making process. There is a moral and ethical need to respect the rights and autonomy of every individual, regardless of age. This does not mean viewing children and adolescents as rational and autonomous decision-makers. This implies that we must promote their developmentally appropriate participation in shared decision-making with parents and physicians. Therefore, instead of asking, "should children and adolescents be granted absolute autonomy in decision making?" we ought to ask, "should we treat children and adolescents like people?" Copyright (c) 2010 Elsevier Masson SAS. All rights reserved.

Implementation of the analytical hierarchy process with VBA in ArcGIS

NASA Astrophysics Data System (ADS)

Marinoni, Oswald

2004-07-01

Decisions on landuse have become progressively more difficult in the last decades. The main reasons for this development lie in the increasing population combined with an increasing demand for new land and resources and in the growing consciousness for sustainable land and resource use. The steady reduction of valuable land leads to an increase of conflicts in land use decision-making processes since more interests are being affected and therefore more stakeholders with different land use interests and different valuation criteria are being involved in the decision-making process. In the course of such a decision process all identified criteria are weighted according to their relative importance. But assigning weights to the relevant criteria quickly becomes a difficult task when a greater number of criteria are being considered, especially with regard to land use decisions where decision makers expect some kind of mapped result it is therefore useful to use procedures that not only help to derive criteria weights but also accelerate the visualisation and mapping of land use assessment results. Both aspects can easily be facilitated in a GIS. This paper focuses the development of an ArcGIS VBA macro which enables the user to derive criteria weights with the analytical hierarchy process and which allows a mapping of the land use assessment results by a weighted summation of GIS raster data sets. A dynamic link library for the calculation of the eigenvalues and eigenvectors of a square matrix is provided.

Images of China in U.S. Foreign Policy Making

DTIC Science & Technology

2014-03-01

process may develop into cognitive dissonance . The individual decision maker could avoid or justify alternative information that opposes his or her...particularly in Acheson’s cognition of China. The establishment of a communist state in mainland China, the formation of a Sino-Soviet alliance, and the...argues that it is difficult to examine policy decisions in a situation without regarding the policy makers’ cognition of the world and 6 the

Helping pregnant teenagers.

PubMed Central

Bluestein, D; Starling, M E

1994-01-01

Teenagers who are pregnant face many difficult issues, and counseling by physicians can be an important source of help. We suggest guidelines for this counseling, beginning with a review of the scope and consequences of adolescent pregnancy. Communication strategies should be aimed at building rapport with techniques such as maintaining confidentiality, avoiding judgmental stances, and gearing communication to cognitive maturity. Techniques for exploring family relationships are useful because these relationships are key influences on subsequent decisions and behaviors. We discuss topics related to abortion and childbearing, such as safety, facilitation of balanced decision making, the use of prenatal care, and the formulation of long-term plans. Physicians who can effectively discuss these topics can help pregnant teenagers make informed decisions and improve their prospects for the future. PMID:7941531

How social and non-social information influence classification decisions: A computational modelling approach.

PubMed

Puskaric, Marin; von Helversen, Bettina; Rieskamp, Jörg

2017-08-01

Social information such as observing others can improve performance in decision making. In particular, social information has been shown to be useful when finding the best solution on one's own is difficult, costly, or dangerous. However, past research suggests that when making decisions people do not always consider other people's behaviour when it is at odds with their own experiences. Furthermore, the cognitive processes guiding the integration of social information with individual experiences are still under debate. Here, we conducted two experiments to test whether information about other persons' behaviour influenced people's decisions in a classification task. Furthermore, we examined how social information is integrated with individual learning experiences by testing different computational models. Our results show that social information had a small but reliable influence on people's classifications. The best computational model suggests that in categorization people first make up their own mind based on the non-social information, which is then updated by the social information.

Institutionalizing Telemedicine Applications: The Challenge of Legitimizing Decision-Making

PubMed Central

Lettieri, Emanuele

2011-01-01

During the last decades a variety of telemedicine applications have been trialed worldwide. However, telemedicine is still an example of major potential benefits that have not been fully attained. Health care regulators are still debating why institutionalizing telemedicine applications on a large scale has been so difficult and why health care professionals are often averse or indifferent to telemedicine applications, thus preventing them from becoming part of everyday clinical routines. We believe that the lack of consolidated procedures for supporting decision making by health care regulators is a major weakness. We aim to further the current debate on how to legitimize decision making about the institutionalization of telemedicine applications on a large scale. We discuss (1) three main requirements— rationality, fairness, and efficiency—that should underpin decision making so that the relevant stakeholders perceive them as being legitimate, and (2) the domains and criteria for comparing and assessing telemedicine applications—benefits and sustainability. According to these requirements and criteria, we illustrate a possible reference process for legitimate decision making about which telemedicine applications to implement on a large scale. This process adopts the health care regulators’ perspective and is made up of 2 subsequent stages, in which a preliminary proposal and then a full proposal are reviewed. PMID:21955510

Institutionalizing telemedicine applications: the challenge of legitimizing decision-making.

PubMed

Zanaboni, Paolo; Lettieri, Emanuele

2011-09-28

During the last decades a variety of telemedicine applications have been trialed worldwide. However, telemedicine is still an example of major potential benefits that have not been fully attained. Health care regulators are still debating why institutionalizing telemedicine applications on a large scale has been so difficult and why health care professionals are often averse or indifferent to telemedicine applications, thus preventing them from becoming part of everyday clinical routines. We believe that the lack of consolidated procedures for supporting decision making by health care regulators is a major weakness. We aim to further the current debate on how to legitimize decision making about the institutionalization of telemedicine applications on a large scale. We discuss (1) three main requirements--rationality, fairness, and efficiency--that should underpin decision making so that the relevant stakeholders perceive them as being legitimate, and (2) the domains and criteria for comparing and assessing telemedicine applications--benefits and sustainability. According to these requirements and criteria, we illustrate a possible reference process for legitimate decision making about which telemedicine applications to implement on a large scale. This process adopts the health care regulators' perspective and is made up of 2 subsequent stages, in which a preliminary proposal and then a full proposal are reviewed.

Right choice, right time: Evaluation of an online decision aid for youth depression.

PubMed

Simmons, Magenta B; Elmes, Aurora; McKenzie, Joanne E; Trevena, Lyndal; Hetrick, Sarah E

2017-08-01

Appropriate treatment for youth depression is an important public health priority. Shared decision making has been recommended, yet no decision aids exist to facilitate this. The main objective of this study was to evaluate an online decision aid for youth depression. An uncontrolled cohort study with pre-decision, immediately post-decision and follow-up measurements. Young people (n=66) aged 12-25 years with mild, mild-moderate or moderate-severe depression were recruited from two enhanced primary care services. Online decision aid with evidence communication, preference elicitation and decision support components. The main outcome measures were ability to make a decision; whether the decision was in line with clinical practice guidelines, personal preferences and values; decisional conflict; perceived involvement; satisfaction with decision; adherence; and depression scores at follow-up. After using the decision aid, clients were more likely to make a decision in line with guideline recommendations (93% vs 70%; P=.004), were more able to make a decision (97% vs 79%; P=.022), had significantly reduced decisional conflict (17.8 points lower (95% CI: 13.3-22.9 points lower) on the Decisional Conflict Scale (range 0-100)) and felt involved and satisfied with their decision. At follow-up, clients had significantly reduced depression symptoms (2.7 points lower (95% CI: 1.3-4.0 points lower) on the Patient Health Questionnaire nine-item scale (range 0-27)) and were adherent to 88% (95% CI: 82%-94%) of treatment courses. A decision aid for youth depression can help ensure evidence-based, client-centred care, promoting collaboration in this often difficult to engage population. © 2016 The Authors. Health Expectations Published by John Wiley & Sons Ltd.

The vexing problem of defining the meaning, role and measurement of values in treatment decision-making.

PubMed

Charles, Cathy; Gafni, Amiram

2014-03-01

Two international movements, evidence-based medicine (EBM) and shared decision-making (SDM) have grappled for some time with issues related to defining the meaning, role and measurement of values/preferences in their respective models of treatment decision-making. In this article, we identify and describe unresolved problems in the way that each movement addresses these issues. The starting point for this discussion is that at least two essential ingredients are needed for treatment decision-making: research information about treatment options and their potential benefits and risks; and the values/preferences of participants in the decision-making process. Both the EBM and SDM movements have encountered difficulties in defining the meaning, role and measurement of values/preferences in treatment decision-making. In the EBM model of practice, there is no clear and consistent definition of patient values/preferences and no guidance is provided on how to integrate these into an EBM model of practice. Methods advocated to measure patient values are also problematic. Within the SDM movement, patient values/preferences tend to be defined and measured in a restrictive and reductionist way as patient preferences for treatment options or attributes of options, while broader underlying value structures are ignored. In both models of practice, the meaning and expected role of physician values in decision-making are unclear. Values clarification exercises embedded in patient decision aids are suggested by SDM advocates to identify and communicate patient values/preferences for different treatment outcomes. Such exercises have the potential to impose a particular decision-making theory and/or process onto patients, which can change the way they think about and process information, potentially impeding them from making decisions that are consistent with their true values. The tasks of clarifying the meaning, role and measurement of values/preferences in treatment decision-making models such as EBM and SDM, and determining whose values ought to count are complex and difficult tasks that will not be resolved quickly. Additional conceptual thinking and research are needed to explore and clarify these issues. To date, the values component of these models remains elusive and underdeveloped.

Clinical decision making in cancer care: a review of current and future roles of patient age.

PubMed

Tranvåg, Eirik Joakim; Norheim, Ole Frithjof; Ottersen, Trygve

2018-05-09

Patient age is among the most controversial patient characteristics in clinical decision making. In personalized cancer medicine it is important to understand how individual characteristics do affect practice and how to appropriately incorporate such factors into decision making. Some argue that using age in decision making is unethical, and how patient age should guide cancer care is unsettled. This article provides an overview of the use of age in clinical decision making and discusses how age can be relevant in the context of personalized medicine. We conducted a scoping review, searching Pubmed for English references published between 1985 and May 2017. References concerning cancer, with patients above the age of 18 and that discussed age in relation to diagnostic or treatment decisions were included. References that were non-medical or concerning patients below the age of 18, and references that were case reports, ongoing studies or opinion pieces were excluded. Additional references were collected through snowballing and from selected reports, guidelines and articles. Three hundred and forty-seven relevant references were identified. Patient age can have many and diverse roles in clinical decision making: Contextual roles linked to access (age influences how fast patients are referred to specialized care) and incidence (association between increasing age and increasing incidence rates for cancer); patient-relevant roles linked to physiology (age-related changes in drug metabolism) and comorbidity (association between increasing age and increasing number of comorbidities); and roles related to interventions, such as treatment (older patients receive substandard care) and outcome (survival varies by age). Patient age is integrated into cancer care decision making in a range of ways that makes it difficult to claim age-neutrality. Acknowledging this and being more transparent about the use of age in decision making are likely to promote better clinical decisions, irrespective of one's normative viewpoint. This overview also provides a starting point for future discussions on the appropriate role of age in cancer care decision making, which we see as crucial for harnessing the full potential of personalized medicine.

EPIDEMIOLOGY IN RISK ASSESSMENT FOR REGULATORY POLICY

EPA Science Inventory

Epidemiology and risk assessment have several of the features needed to make the difficult decisions required in setting standards for levels of toxic agents in the workplace and environment. hey differ in their aims, orientation, and time scale. While the distribution of disease...

ISSUES AND CHALLENGES IN MODELING CHILDREN'S LONGITUDINAL EXPOSURES: AN OZONE STUDY

EPA Science Inventory

Modeling children's exposures is a complicated, data-intensive process. Modeling longitudinal exposures, which are important for regulatory decision making, especially for most air toxics, adds another level of complexity and data requirements. Because it is difficult to model in...

Setting Environmental Standards

ERIC Educational Resources Information Center

Fishbein, Gershon

1975-01-01

Recent court decisions have pointed out the complexities involved in setting environmental standards. Environmental health is composed of multiple causative agents, most of which work over long periods of time. This makes the cause-and-effect relationship between health statistics and environmental contaminant exposures difficult to prove in…

A Diagnostics Tool to detect ensemble forecast system anomaly and guide operational decisions

NASA Astrophysics Data System (ADS)

Park, G. H.; Srivastava, A.; Shrestha, E.; Thiemann, M.; Day, G. N.; Draijer, S.

2017-12-01

The hydrologic community is moving toward using ensemble forecasts to take uncertainty into account during the decision-making process. The New York City Department of Environmental Protection (DEP) implements several types of ensemble forecasts in their decision-making process: ensemble products for a statistical model (Hirsch and enhanced Hirsch); the National Weather Service (NWS) Advanced Hydrologic Prediction Service (AHPS) forecasts based on the classical Ensemble Streamflow Prediction (ESP) technique; and the new NWS Hydrologic Ensemble Forecasting Service (HEFS) forecasts. To remove structural error and apply the forecasts to additional forecast points, the DEP post processes both the AHPS and the HEFS forecasts. These ensemble forecasts provide mass quantities of complex data, and drawing conclusions from these forecasts is time-consuming and difficult. The complexity of these forecasts also makes it difficult to identify system failures resulting from poor data, missing forecasts, and server breakdowns. To address these issues, we developed a diagnostic tool that summarizes ensemble forecasts and provides additional information such as historical forecast statistics, forecast skill, and model forcing statistics. This additional information highlights the key information that enables operators to evaluate the forecast in real-time, dynamically interact with the data, and review additional statistics, if needed, to make better decisions. We used Bokeh, a Python interactive visualization library, and a multi-database management system to create this interactive tool. This tool compiles and stores data into HTML pages that allows operators to readily analyze the data with built-in user interaction features. This paper will present a brief description of the ensemble forecasts, forecast verification results, and the intended applications for the diagnostic tool.

Choosing the appropriate treatment setting: which information and decision-making needs do adult inpatients with mental disorders have? A qualitative interview study

PubMed Central

Kivelitz, Laura; Härter, Martin; Mohr, Jil; Melchior, Hanne; Goetzmann, Lutz; Warnke, Max Holger; Kleinschmidt, Silke; Dirmaier, Jörg

2018-01-01

Background Decisions on medical treatment setting are perceived as important but often difficult to make for patients with mental disorders. Shared decision-making as a strategy to decrease decisional conflict has been recommended, but is not yet widely implemented. This study aimed to investigate the information needs and the decision-making preferences of patients with mental disorders prior to the decision for a certain treatment setting. The results will serve as a prerequisite for the development of a high-quality patient decision aid (PtDA) regarding the treatment setting decision. Methods We conducted retrospective individual semi-structured interviews with n=24 patients with mental disorders in three psychotherapeutic inpatient care units. The interviews were audiotaped, transcribed, coded, and content-analyzed. Results The majority of the patients wanted to be involved in the decision-making process. They reported high information needs regarding treatment options in order to feel empowered to participate adequately in the decision for a certain treatment setting. However, some patients did not want to participate or receive information, for example, because of their high burden of mental disorder. Whereas the majority were satisfied with the extent they were involved in the decision, few participants felt sufficiently informed about treatment options. Most patients reported that a decision aid regarding an appropriate treatment setting would have been helpful for them. Important information that should be included in a PtDA was general information about mental illness, effective treatment options, specific information about the different treatment settings, and access to treatment. Discussion The identified information and decision-making needs provide a valuable basis for the development of a PtDA aiming to support patients and caregivers regarding the decision for an adequate treatment setting. As preferences for participation vary among patients and also depend on the current mental state, a flexible approach is needed to meet patients’ individual wishes and needs. PMID:29805250

Choosing the appropriate treatment setting: which information and decision-making needs do adult inpatients with mental disorders have? A qualitative interview study.

PubMed

Kivelitz, Laura; Härter, Martin; Mohr, Jil; Melchior, Hanne; Goetzmann, Lutz; Warnke, Max Holger; Kleinschmidt, Silke; Dirmaier, Jörg

2018-01-01

Decisions on medical treatment setting are perceived as important but often difficult to make for patients with mental disorders. Shared decision-making as a strategy to decrease decisional conflict has been recommended, but is not yet widely implemented. This study aimed to investigate the information needs and the decision-making preferences of patients with mental disorders prior to the decision for a certain treatment setting. The results will serve as a prerequisite for the development of a high-quality patient decision aid (PtDA) regarding the treatment setting decision. We conducted retrospective individual semi-structured interviews with n=24 patients with mental disorders in three psychotherapeutic inpatient care units. The interviews were audiotaped, transcribed, coded, and content-analyzed. The majority of the patients wanted to be involved in the decision-making process. They reported high information needs regarding treatment options in order to feel empowered to participate adequately in the decision for a certain treatment setting. However, some patients did not want to participate or receive information, for example, because of their high burden of mental disorder. Whereas the majority were satisfied with the extent they were involved in the decision, few participants felt sufficiently informed about treatment options. Most patients reported that a decision aid regarding an appropriate treatment setting would have been helpful for them. Important information that should be included in a PtDA was general information about mental illness, effective treatment options, specific information about the different treatment settings, and access to treatment. The identified information and decision-making needs provide a valuable basis for the development of a PtDA aiming to support patients and caregivers regarding the decision for an adequate treatment setting. As preferences for participation vary among patients and also depend on the current mental state, a flexible approach is needed to meet patients' individual wishes and needs.

Leadership of risk decision making in a complex, technology organization: The deliberative decision making model

NASA Astrophysics Data System (ADS)

Flaming, Susan C.

2007-12-01

The continuing saga of satellite technology development is as much a story of successful risk management as of innovative engineering. How do program leaders on complex, technology projects manage high stakes risks that threaten business success and satellite performance? This grounded theory study of risk decision making portrays decision leadership practices at one communication satellite company. Integrated product team (IPT) leaders of multi-million dollar programs were interviewed and observed to develop an extensive description of the leadership skills required to navigate organizational influences and drive challenging risk decisions to closure. Based on the study's findings the researcher proposes a new decision making model, Deliberative Decision Making, to describe the program leaders' cognitive and organizational leadership practices. This Deliberative Model extends the insights of prominent decision making models including the rational (or classical) and the naturalistic and qualifies claims made by bounded rationality theory. The Deliberative Model describes how leaders proactively engage resources to play a variety of decision leadership roles. The Model incorporates six distinct types of leadership decision activities, undertaken in varying sequence based on the challenges posed by specific risks. Novel features of the Deliberative Decision Model include: an inventory of leadership methods for managing task challenges, potential stakeholder bias and debates; four types of leadership meta-decisions that guide decision processes, and aligned organizational culture. Both supporting and constraining organizational influences were observed as leaders managed major risks, requiring active leadership on the most difficult decisions. Although the company's engineering culture emphasized the importance of data-based decisions, the uncertainties intrinsic to satellite risks required expert engineering judgment to be exercised throughout. An investigation into the co-variation of decision methods with uncertainty suggests that perceived risk severity may serve as a robust indicator for choices about decision practices. The Deliberative Decision processes incorporate multiple organizational and cultural controls as cross-checks to mitigate potential parochial bias of individuals, stakeholder groups, or leaders. Overall the Deliberative Decision framework describes how expert leadership practices, supportive organizational systems along with aligned cultural values and behavioral norms help leaders drive high stakes risk decisions to closure in this complex, advanced-technology setting.

Public health decisions: Actions and consequences☆

PubMed Central

Pohl, H.R.; Jones, D.E.; Holler, J.S.; Murray, H.E.

2017-01-01

The goal of public health is to promote the best possible health for the whole population. Public health issues are numerous and can be unbelievably complex in form, scope, and possible consequence. Most public health decisions involve assessing several different options, weighing the respective benefits and risks of those options, and making difficult decisions that hopefully provide the greatest benefit to the affected populations. Many risk management decisions involve a variety of societal factors which modify risk assessment choices. The purpose of this paper is to point out difficulties in making decisions that impact public health. The intent of such decisions is to improve public health, but as illustrated in the paper, there can be unintended adverse consequences. Such unplanned issues require continued attention and efforts for responsible officials in the protection of environmental public health. This article presents examples of such events, when in the past, it was necessary to assess and regulate a number of potentially hazardous chemicals commonly used as insecticides, gasoline additives, and wood preservatives. PMID:25092130

A Multicriteria Decision Making Approach for Estimating the Number of Clusters in a Data Set

PubMed Central

Peng, Yi; Zhang, Yong; Kou, Gang; Shi, Yong

2012-01-01

Determining the number of clusters in a data set is an essential yet difficult step in cluster analysis. Since this task involves more than one criterion, it can be modeled as a multiple criteria decision making (MCDM) problem. This paper proposes a multiple criteria decision making (MCDM)-based approach to estimate the number of clusters for a given data set. In this approach, MCDM methods consider different numbers of clusters as alternatives and the outputs of any clustering algorithm on validity measures as criteria. The proposed method is examined by an experimental study using three MCDM methods, the well-known clustering algorithm–k-means, ten relative measures, and fifteen public-domain UCI machine learning data sets. The results show that MCDM methods work fairly well in estimating the number of clusters in the data and outperform the ten relative measures considered in the study. PMID:22870181

Support Tool in the Diagnosis of Major Depressive Disorder

NASA Astrophysics Data System (ADS)

Nunes, Luciano Comin; Pinheiro, Plácido Rogério; Pequeno, Tarcísio Cavalcante; Pinheiro, Mirian Calíope Dantas

Major Depressive Disorder have been responsible for millions of professionals temporary removal, and even permanent, from diverse fields of activities around the world, generating damage to social, financial, productive systems and social security, and especially damage to the image of the individual and his family that these disorders produce in individuals who are patients, characteristics that make them stigmatized and discriminated into their society, making difficult their return to the production system. The lack of early diagnosis has provided reactive and late measures, only when the professional suffering psychological disorder is already showing signs of incapacity for working and social relationships. This article aims to assist in the decision making to establish early diagnosis of these types of psychological disorders. It presents a proposal for a hybrid model composed of expert system structured methodologies for decision support (Multi-Criteria Decision Analysis - MCDA) and representations of knowledge structured in logical rules of production and probabilities (Artificial Intelligence - AI).

Negotiation and Decision Making with Collaborative Software: How MarineMap 'Changed the Game' in California's Marine Life Protected Act Initiative.

PubMed

Cravens, Amanda E

2016-02-01

Environmental managers and planners have become increasingly enthusiastic about the potential of decision support tools (DSTs) to improve environmental decision-making processes as information technology transforms many aspects of daily life. Discussions about DSTs, however, rarely recognize the range of ways software can influence users' negotiation, problem-solving, or decision-making strategies and incentives, in part because there are few empirical studies of completed processes that used technology. This mixed-methods study-which draws on data from approximately 60 semi-structured interviews and an online survey--examines how one geospatial DST influenced participants' experiences during a multi-year marine planning process in California. Results suggest that DSTs can facilitate communication by creating a common language, help users understand the geography and scientific criteria in play during the process, aid stakeholders in identifying shared or diverging interests, and facilitate joint problem solving. The same design features that enabled the tool to aid in decision making, however, also presented surprising challenges in certain circumstances by, for example, making it difficult for participants to discuss information that was not spatially represented on the map-based interface. The study also highlights the importance of the social context in which software is developed and implemented, suggesting that the relationship between the software development team and other participants may be as important as technical software design in shaping how DSTs add value. The paper concludes with considerations to inform the future use of DSTs in environmental decision-making processes.

Negotiation and Decision Making with Collaborative Software: How MarineMap `Changed the Game' in California's Marine Life Protected Act Initiative

NASA Astrophysics Data System (ADS)

Cravens, Amanda E.

2016-02-01

Environmental managers and planners have become increasingly enthusiastic about the potential of decision support tools (DSTs) to improve environmental decision-making processes as information technology transforms many aspects of daily life. Discussions about DSTs, however, rarely recognize the range of ways software can influence users' negotiation, problem-solving, or decision-making strategies and incentives, in part because there are few empirical studies of completed processes that used technology. This mixed-methods study—which draws on data from approximately 60 semi-structured interviews and an online survey—examines how one geospatial DST influenced participants' experiences during a multi-year marine planning process in California. Results suggest that DSTs can facilitate communication by creating a common language, help users understand the geography and scientific criteria in play during the process, aid stakeholders in identifying shared or diverging interests, and facilitate joint problem solving. The same design features that enabled the tool to aid in decision making, however, also presented surprising challenges in certain circumstances by, for example, making it difficult for participants to discuss information that was not spatially represented on the map-based interface. The study also highlights the importance of the social context in which software is developed and implemented, suggesting that the relationship between the software development team and other participants may be as important as technical software design in shaping how DSTs add value. The paper concludes with considerations to inform the future use of DSTs in environmental decision-making processes.

Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.

PubMed

Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C

2015-11-01

The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training. © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.

Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics*

PubMed Central

Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C

2015-01-01

The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the ‘can't intubate, can't oxygenate’ situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training. PMID:26449292

The Role of Psychological Adjustment in the Decision-making Process for Voluntary Termination of Pregnancy.

PubMed

Sereno, Sara; Leal, Isabel; Maroco, João

2013-07-01

This study's objective was to evaluate the role of psychological adjustment in the decision-making process to have an abortion and explore individual variables that might influence this decision. In this cross-sectional study, we sequentially enrolled 150 women who made the decision to voluntarily terminate a pregnancy in Maternity Dr. Alfredo da Costa, in Lisbon, Portugal, between September 2008 and June 2009. The instruments were the Depression, Anxiety and Stress Scale (DASS), Satisfaction with Social Support Scale (SSSS), Emotional Assessment Scale (EAS), Decision Conflict Scale (DCS), and Beliefs and Values Questionnaire (BVQ). We analyzed the data using Student's T-tests, MANOVA, ANOVA, Tukey's post-hoc tests and CATPCA. Statistically significant effects were accepted for p<0.05. The participants found the decision difficult and emotionally demanding, although they also identified it as a low conflict decision. The prevailing emotions were sadness, fear and stress; but despite these feelings, the participants remained psychologically adjusted in the moment they decided to have an abortion. The resolution to terminate the pregnancy was essentially shared with supportive people and it was mostly motivated by socio-economic issues. The different beliefs and values found in this sample, and their possible associations are discussed. Despite high levels of stress, the women were psychologically adjusted at the time of making the decision to terminate the pregnancy. However, opposing what has been previously reported, the women presented high levels of sadness and fear, showing that this decision was hard to make, triggering disruptive emotions.

Allocating health care: cost-utility analysis, informed democratic decision making, or the veil of ignorance?

PubMed

Goold, S D

1996-01-01

Assuming that rationing health care is unavoidable, and that it requires moral reasoning, how should we allocate limited health care resources? This question is difficult because our pluralistic, liberal society has no consensus on a conception of distributive justice. In this article I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, liberalism, and fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge competing processes so that rationing decisions are, to some extent, self-imposed. I also examine the processes' feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditably assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the veil of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, that relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at the community or organizational level.

Communicating about bioenergy sustainability.

PubMed

Dale, Virginia H; Kline, Keith L; Perla, Donna; Lucier, Al

2013-02-01

Defining and measuring sustainability of bioenergy systems are difficult because the systems are complex, the science is in early stages of development, and there is a need to generalize what are inherently context-specific enterprises. These challenges, and the fact that decisions are being made now, create a need for improved communications among scientists as well as between scientists and decision makers. In order for scientists to provide information that is useful to decision makers, they need to come to an agreement on how to measure and report potential risks and benefits of diverse energy alternatives in a way that allows decision makers to compare options. Scientists also need to develop approaches that contribute information about problems and opportunities relevant to policy and decision making. The need for clear communication is especially important at this time when there is a plethora of scientific papers and reports and it is difficult for the public or decision makers to assess the merits of each analysis. We propose three communication guidelines for scientists whose work can contribute to decision making: (1) relationships between the question and the analytical approach should be clearly defined and make common sense; (2) the information should be presented in a manner that non-scientists can understand; and (3) the implications of methods, assumptions, and limitations should be clear. The scientists' job is to analyze information to build a better understanding of environmental, cultural, and socioeconomic aspects of the sustainability of energy alternatives. The scientific process requires transparency, debate, review, and collaboration across disciplines and time. This paper serves as an introduction to the papers in the special issue on "Sustainability of Bioenergy Systems: Cradle to Grave" because scientific communication is essential to developing more sustainable energy systems. Together these four papers provide a framework under which the effects of bioenergy can be assessed and compared to other energy alternatives to foster sustainability.

Antenatal counselling for parents facing an extremely preterm birth: limitations of the medical evidence.

PubMed

Janvier, Annie; Lorenz, John M; Lantos, John D

2012-08-01

When physicians are asked for a consult for women in premature labour, they face a complex set of challenges. Policy statements recommend that women be given detailed information about the risks of various outcomes, including death, long-term disability and various specific neonatal problems. Both personal narratives and studies suggest that parents also base their decisions on factors other than the probabilistic facts about expected outcomes. Statistics are difficult to understand at any time. Rational decision-making may be difficult when taking life-and-death decisions. Furthermore, the role of emotions is not discussed in peri-viability guidelines. We argue against trying to tell parents every fact that we think might be relevant to their decision. This may be overwhelming for many parents. Instead, doctors should try to discern, on a case-by-case basis, what particular parents want and need. Information and delivery of information should be personalized. Unfortunately, evidence in this area is limited. © 2012 The Author(s)/Acta Paediatrica © 2012 Foundation Acta Paediatrica.

A Pilot Study of Pedestrians with Visual Impairments Detecting Traffic Gaps and Surges Containing Hybrid Vehicles

PubMed Central

Emerson, Robert Wall; Naghshineh, Koorosh; Hapeman, Julie; Wiener, William

2010-01-01

The increasing number of hybrid and quiet internal combustion engine vehicles may impact the travel abilities of pedestrians who are blind. Pedestrians who rely on auditory cues for structuring their travel may face challenges in making crossing decisions in the presence of quiet vehicles. This article describes results of initial studies looking at the crossing decisions of pedestrians who are blind at an uncontrolled crossing (no traffic control) and a light controlled intersection. The presence of hybrid vehicles was a factor in each situation. At the uncontrolled crossing, Toyota hybrids were most difficult to detect but crossing decisions were made more often in small gaps ended by a Honda hybrid. These effects were seen only at speed under 20 mph. At the light controlled intersection, parallel surges of traffic were most difficult to detect when made up only of a Ford Escape hybrid. Results suggest that more controlled studies of vehicle characteristics impacting crossing decisions of pedestrians who are blind are warranted. PMID:21379367

A Pilot Study of Pedestrians with Visual Impairments Detecting Traffic Gaps and Surges Containing Hybrid Vehicles.

PubMed

Emerson, Robert Wall; Naghshineh, Koorosh; Hapeman, Julie; Wiener, William

2011-03-01

The increasing number of hybrid and quiet internal combustion engine vehicles may impact the travel abilities of pedestrians who are blind. Pedestrians who rely on auditory cues for structuring their travel may face challenges in making crossing decisions in the presence of quiet vehicles. This article describes results of initial studies looking at the crossing decisions of pedestrians who are blind at an uncontrolled crossing (no traffic control) and a light controlled intersection. The presence of hybrid vehicles was a factor in each situation. At the uncontrolled crossing, Toyota hybrids were most difficult to detect but crossing decisions were made more often in small gaps ended by a Honda hybrid. These effects were seen only at speed under 20 mph. At the light controlled intersection, parallel surges of traffic were most difficult to detect when made up only of a Ford Escape hybrid. Results suggest that more controlled studies of vehicle characteristics impacting crossing decisions of pedestrians who are blind are warranted.

Risky decision-making in children with and without ADHD: A prospective study.

PubMed

Humphreys, Kathryn L; Tottenham, Nim; Lee, Steve S

2018-02-01

Learning from past decisions can enhance successful decision-making. It is unclear whether difficulties in learning from experience may contribute to risky decision-making, which may be altered among individuals with attention-deficit/hyperactivity disorder (ADHD). This study follows 192 children with and without ADHD aged 5 to 10 years for approximately 2.5 years and examines their risky decision-making using the Balloon Emotional Learning Task (BELT), a computerized assessment of sequential risky decision-making in which participants pump up a series of virtual balloons for points. The BELT contains three task conditions: one with a variable explosion point, one with a stable and early explosion point, and one with a stable and late explosion point. These conditions may be learned via experience on the task. Contrary to expectations, ADHD status was not found to be related to greater risk-taking on the BELT, and among younger children ADHD status is in fact associated with reduced risk-taking. In addition, the typically-developing children without ADHD showed significant learning-related gains on both stable task conditions. However, the children with ADHD demonstrated learning on the condition with a stable and early explosion point, but not on the condition with the stable and late explosion point, in which more pumps are required before learning when the balloon will explode. Learning during decision-making may be more difficult for children with ADHD. Because adapting to changing environmental demands requires the use of feedback to guide future behavior, negative outcomes associated with childhood ADHD may partially reflect difficulties in learning from experience.

Effects of Healthy Aging and Mild Cognitive Impairment on a Real-Life Decision-Making Task.

PubMed

Pertl, Marie-Theres; Benke, Thomas; Zamarian, Laura; Delazer, Margarete

2017-01-01

In this study, we investigated the effects of age and of mild cognitive impairment (MCI) on decision making under risk by adopting a task representing real-life health-related situations and involving complex numerical information. Moreover, we assessed the relationship of real-life decision making to other cognitive functions such as number processing, executive functions, language, memory, and attention. For this reason, we compared the performance of 19 healthy, relatively younger adults with that of 18 healthy older adults and the performance of the 18 healthy older adults with that of 17 patients with MCI. Results indicated difficulties in real-life decision making for the healthy older adults compared with the healthy, relatively younger adults. Difficulties of patients with MCI relative to the healthy older adults arose in particular in difficult items requiring processing of frequencies and fractions. Significant effects of age and of MCI in processing frequencies were also evident in a ratio number comparison task. Decision-making performance of healthy participants and of the patient group correlated significantly with number processing. There was a further significant correlation with executive functions for the healthy participants and with reading comprehension for the patients. Our results suggest that healthy older individuals and patients with MCI make less advantageous decisions when the information is complex and high demands are put on executive functions and numerical abilities. Moreover, we show that executive functions and numerical abilities are not only essential in laboratory gambling tasks but also in more realistic and ecological decision situations within the health context.

Managing the Risks of Climate Change and Terrorism

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rosa, Eugene; Dietz, Tom; Moss, Richard H.

2012-04-07

Society has difficult decisions to make about how best to allocate its resources to ensure future sustainability. Risk assessment can be a valuable tool: it has long been used to support decisions to address environmental problems. But in a time when the risks to sustainability range from climate change to terrorism, applying risk assessment to sustainability will require careful rethinking. For new threats, we will need a new approach to risk assessment.

Cost-effectiveness analysis: problems and promise for evaluating medical technology

NASA Astrophysics Data System (ADS)

Juday, Timothy R.

1994-12-01

Although using limited financial resources in the most beneficial way, in principle, a laudable goal, actually developing standards for measuring the cost-effectiveness of medical technologies and incorporating them into the coverage process is a much more difficult proposition. Important methodological difficulties include determining how to compare a technology to its leading alternative, defining costs, incorporating patient preferences, and defining health outcomes. In addition, more practical questions must be addressed. These questions include: who does the analysis? who makes the decisions? which technologies to evaluate? what resources are required? what is the political and legal environment? how much is a health outcome worth? The ultimate question that must be answered is what is a health outcome worth? Cost-effectiveness analysis cannot answer this question; it only enables comparison of cost-effectiveness ratios across technologies. In order to determine whether a technology should be covered, society or individual insurers must determine how much they are willing to pay for the health benefits. Conducting cost-effectiveness analysis will not remove the need to make difficult resource allocation decisions; however, explicitly examining the tradeoffs involved in these decisions should help to improve the process.

[Medical expert systems and clinical needs].

PubMed

Buscher, H P

1991-10-18

The rapid expansion of computer-based systems for problem solving or decision making in medicine, the so-called medical expert systems, emphasize the need for reappraisal of their indication and value. Where specialist knowledge is required, in particular where medical decisions are susceptible to error these systems will probably serve as a valuable support. In the near future computer-based systems should be able to aid the interpretation of findings of technical investigations and the control of treatment, especially where rapid reactions are necessary despite the need of complex analysis of investigated parameters. In the distant future complete support of diagnostic procedures from the history to final diagnosis is possible. It promises to be particularly attractive for the diagnosis of seldom diseases, for difficult differential diagnoses, and in the decision making in the case of expensive, risky or new diagnostic or therapeutic methods. The physician needs to be aware of certain dangers, ranging from misleading information up to abuse. Patient information depends often on subjective reports and error-prone observations. Although basing on problematic knowledge computer-born decisions may have an imperative effect on medical decision making. Also it must be born in mind that medical decisions should always combine the rational with a consideration of human motives.

Making decisions at the end of life when caring for a person with dementia: a literature review to explore the potential use of heuristics in difficult decision-making.

PubMed

Mathew, R; Davies, N; Manthorpe, J; Iliffe, S

2016-07-19

Decision-making, when providing care and treatment for a person with dementia at the end of life, can be complex and challenging. There is a lack of guidance available to support practitioners and family carers, and even those experienced in end of life dementia care report a lack of confidence in decision-making. It is thought that the use of heuristics (rules of thumb) may aid decision-making. The aim of this study is to identify whether heuristics are used in end of life dementia care, and if so, to identify the context in which they are being used. A narrative literature review was conducted taking a systematic approach to the search strategy, using the Centre for Reviews and Dissemination guidelines. Rapid appraisal methodology was used in order to source specific and relevant literature regarding the use of heuristics in end of life dementia care. A search using terms related to dementia, palliative care and decision-making was conducted across 4 English language electronic databases (MEDLINE, EMBASE, PsycINFO and CINAHL) in 2015. The search identified 12 papers that contained an algorithm, guideline, decision tool or set of principles that we considered compatible with heuristic decision-making. The papers addressed swallowing and feeding difficulties, the treatment of pneumonia, management of pain and agitation, rationalising medication, ending life-sustaining treatment, and ensuring a good death. The use of heuristics in palliative or end of life dementia care is not described in the research literature. However, this review identified important decision-making principles, which are largely a reflection of expert opinion. These principles may have the potential to be developed into simple heuristics that could be used in practice. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Making decisions at the end of life when caring for a person with dementia: a literature review to explore the potential use of heuristics in difficult decision-making

PubMed Central

Mathew, R; Davies, N; Manthorpe, J; Iliffe, S

2016-01-01

Objective Decision-making, when providing care and treatment for a person with dementia at the end of life, can be complex and challenging. There is a lack of guidance available to support practitioners and family carers, and even those experienced in end of life dementia care report a lack of confidence in decision-making. It is thought that the use of heuristics (rules of thumb) may aid decision-making. The aim of this study is to identify whether heuristics are used in end of life dementia care, and if so, to identify the context in which they are being used. Design A narrative literature review was conducted taking a systematic approach to the search strategy, using the Centre for Reviews and Dissemination guidelines. Rapid appraisal methodology was used in order to source specific and relevant literature regarding the use of heuristics in end of life dementia care. Data sources A search using terms related to dementia, palliative care and decision-making was conducted across 4 English language electronic databases (MEDLINE, EMBASE, PsycINFO and CINAHL) in 2015. Results The search identified 12 papers that contained an algorithm, guideline, decision tool or set of principles that we considered compatible with heuristic decision-making. The papers addressed swallowing and feeding difficulties, the treatment of pneumonia, management of pain and agitation, rationalising medication, ending life-sustaining treatment, and ensuring a good death. Conclusions The use of heuristics in palliative or end of life dementia care is not described in the research literature. However, this review identified important decision-making principles, which are largely a reflection of expert opinion. These principles may have the potential to be developed into simple heuristics that could be used in practice. PMID:27436665

Moral Fantasy in Genetic Engineering.

ERIC Educational Resources Information Center

Boone, C. Keith

1984-01-01

Discusses the main ethical issues generated by the new genetics and suggests ways to think about them. Concerns include "playing God," violation of the natural order of the universe, and abuse of genetic technology. Critical distinctions for making difficult decisions about genetic engineering issues are noted. (DH)

Tampa Bay Ecosystem Services Demonstration Pilot Phase 2 web site

EPA Science Inventory

The value of nature's benefits is difficult to consider in environmental decision-making since ecosystem goods and services are usually not well measured or quantified in economic terms. The Tampa Bay Estuary Program, Tampa Bay Regional Planning Council, the U.S. Environmental Pr...

The Key Pieces of the Career Survival and Success Puzzle.

ERIC Educational Resources Information Center

Simonetti, Jack L.

1999-01-01

Analysis of career-success factors identified by 5,000 managers yielded 10 key pieces: excellent performance record, communication skills, interpersonal skills, personality, skill currency, significant work experiences, power, ability to withstand pressure, ability to make difficult decisions, and having a mentor. (SK)

[Medical futility and family obstinacy in intensive therapy. When to stop and when to keep going?

PubMed

Grinberg, Alejandro R; Tripodoro, Vilma A

2017-01-01

There have been several recent publications related to therapeutic obstinacy and futility in the Intensive Care Unit. However, little has been published about "the family obstinacy" in persisting with invasive measures in seriously ill patients, despite the appropriate information provided to them about the patient's poor short-term prognosis. On certain occasions, these critical patients are unable to make decisions on the proposed treatments and, unfortunately, many of them have not previously indicated their preferences in terms of limits to invasive measures (advanced directives). Thus, the patient's relatives are the ones who finally assume this arduous task and, in several occasions, they make decisions that do not correspond with the patient's actual wishes. Palliative medicine is of invaluable help in the difficult goal of improving communication among doctors, patients and patients relatives. Limits to intervention can be difficult and vague, generating multiple problems in the decision-making process. On certain occasions and despite adequate information provided by therapists and palliative care doctors, patients' relatives do not accept professional directives indicating to stop invasive interventions. Understanding futility justification may be relevant to the appropriate resolution of these disputes. In this article, we intend to discuss the subject "futility in Intensive Care Unit" and how to face the seldom addressed "family obstinacy" issue in potentially unrecoverable situations, despite adequate medical information.

Testicular tissue cryopreservation in prepubertal male children: an analysis of parental decision-making.

PubMed

Ginsberg, Jill P; Li, Yimei; Carlson, Claire A; Gracia, Clarisa R; Hobbie, Wendy L; Miller, Victoria A; Mulhall, John; Shnorhavorian, Margarett; Brinster, Ralph L; Kolon, Thomas F

2014-09-01

Infertility is an unfortunate treatment-related consequence for some pediatric malignancies as well as some non-malignant conditions treated with stem cell transplant. Unlike pubertal males, prepubertal males cannot produce semen for cryopreservation. This manuscript reports on the acceptability and safety of a multi-institutional protocol for offering testicular tissue cryopreservation to families of prepubertal male children at highest risk for infertility. Data on decision influences, decision-making control, and emotional state when considering this option are described. Prepubertal males facing gonadotoxic therapy were offered testicular cryopreservation. Post-biopsy, patients were followed for acute side effects. In addition, parents and patients were asked to complete questionnaires, whether or not they chose to cryopreserve tissue. Seventy-four prepubertal male children were approached. Fifty-seven families (77%) consented to the testicular biopsy; 48 of 57 underwent the procedure. There was one post-operative side effect. Parents who agreed to testicular cryopreservation and those that did not felt in control of this decision. Parents who consented to the biopsy and refusers were not deterred by the experimental nature of the protocol. An important decision-making influence was the risk of the biopsy. Biopsy and cryopreservation of testicular tissue from prepubertal male children was performed successfully and safely at three institutions. Parents faced with this option at diagnosis can make an informed decision and weigh carefully the risks and benefits. Although asked to make a decision soon after they were given a difficult diagnosis, parents uniformly felt in control of this decision. © 2014 Wiley Periodicals, Inc.

Caregivers’ perspectives on decision making about lung transplantation in cystic fibrosis

PubMed Central

Dellon, Elisabeth P.; Shores, Mitchell D.; Nelson, Katherine I.; Wolfe, Joanne; Noah, Terry L.; Hanson, Laura C.

2013-01-01

Context Lung transplantation extends survival for some patients with advanced cystic fibrosis, but it is complicated, has many potential risks, and its outcomes are difficult to predict. No standards exist for informed decision making about transplantation. Objective To assess decision making from the perspective of caregivers of patients who faced the transplant decision before dying of cystic fibrosis or transplant complications. Design Semistructured interviews with descriptive and qualitative content analysis. Participants Twenty-eight caregivers of patients with cystic fibrosis who received care at our center and died between 1996 and 2006. Results Of 28 patients who considered lung transplantation, 19 (68%) received transplants, 6 (21%) died while waiting for transplant, and 3 (11%) declined transplant. Three caregivers (11%) thought that the patient did not fully understand the reason for transplant referral. Five (18%) thought that the patient did not fully understand potential risks. Ten (36%) thought that alternatives were not fully understood. The only alternatives to transplant identified, progressive illness and the possibility of earlier death without transplant, were unacceptable to most. Thirteen caregivers (46%) reported that the patient thought that declining transplant was not an option. Caregivers described the decision as “easy” for 19 (68%), often expressing a sentiment of “do or die.” Those who described the decision as “easy” recalled fewer elements of informed decision making. Conclusions From caregivers’ reports, patients with cystic fibrosis may not fully understand risks of and alternatives to lung transplantation. Because a strong desire to prolong life necessitates honest communication about potential outcomes, interventions are needed to facilitate high-quality decision making. PMID:20050454

Family involvement in decision making for people with dementia in residential aged care: a systematic review of quantitative literature.

PubMed

Petriwskyj, Andrea; Gibson, Alexandra; Parker, Deborah; Banks, Susan; Andrews, Sharon; Robinson, Andrew

2014-06-01

Ensuring older adults' involvement in their care is accepted as good practice and is vital, particularly for people with dementia, whose care and treatment needs change considerably over the course of the illness. However, involving family members in decision making on people's behalf is still practically difficult for staff and family. The aim of this review was to identify and appraise the existing quantitative evidence about family involvement in decision making for people with dementia living in residential aged care. The present Joanna Briggs Institute (JBI) metasynthesis assessed studies that investigated involvement of family members in decision making for people with dementia in residential aged care settings. While quantitative and qualitative studies were included in the review, this paper presents the quantitative findings. A comprehensive search of 15 electronic databases was performed. The search was limited to papers published in English, from 1990 to 2013. Twenty-six studies were identified as being relevant; 10 were quantitative, with 1 mixed method study. Two independent reviewers assessed the studies for methodological validity and extracted the data using the JBI Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). The findings were synthesized and presented in narrative form. The findings related to decisions encountered and made by family surrogates, variables associated with decisions, surrogates' perceptions of, and preferences for, their roles, as well as outcomes for people with dementia and their families. The results identified patterns within, and variables associated with, surrogate decision making, all of which highlight the complexity and variation regarding family involvement. Attention needs to be paid to supporting family members in decision making in collaboration with staff.

[Withdrawal of artificial nutrition and hydration in severe stroke: medical, legal and ethical considerations].

PubMed

Tannier, C; Crozier, S; Zuber, M; Constantinides, Y; Delezie, E; Gisquet, E; Grignoli, N; Lamy, C; Louvet, F; Pinel, J-F

2015-02-01

In the majority of cases, severe stroke is accompanied by difficulty in swallowing and an altered state of consciousness requiring artificial nutrition and hydration. Because of their artificial nature, nutrition and hydration are considered by law as treatment rather basic care. Withdrawal of these treatments is dictated by the refusal of unreasonable obstinacy enshrined in law and is justified by the risk of severe disability and very poor quality of life. It is usually the last among other withholding and withdrawal decisions which have already been made during the long course of the disease. Reaching a collegial consensus on a controversial decision such as artificial nutrition and hydration withdrawal is a difficult and complex process. The reluctance for such decisions is mainly due to the symbolic value of food and hydration, to the fear of "dying badly" while suffering from hunger and thirst, and to the difficult distinction between this medical act and euthanasia. The only way to overcome such reluctance is to ensure flawless accompaniment, associating sedation and appropriate comfort care with a clear explanation (with relatives but also caregivers) of the rationale and implications of this type of decision. All teams dealing with this type of situation must have thoroughly thought through the medical, legal and ethical considerations involved in making this difficult decision. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

An intelligent, knowledge-based multiple criteria decision making advisor for systems design

NASA Astrophysics Data System (ADS)

Li, Yongchang

In systems engineering, design and operation of systems are two main problems which always attract researcher's attentions. The accomplishment of activities in these problems often requires proper decisions to be made so that the desired goal can be achieved, thus, decision making needs to be carefully fulfilled in the design and operation of systems. Design is a decision making process which permeates through out the design process, and is at the core of all design activities. In modern aircraft design, more and more attention is paid to the conceptual and preliminary design phases so as to increase the odds of choosing a design that will ultimately be successful at the completion of the design process, therefore, decisions made during these early design stages play a critical role in determining the success of a design. Since aerospace systems are complex systems with interacting disciplines and technologies, the Decision Makers (DMs) dealing with such design problems are involved in balancing the multiple, potentially conflicting attributes/criteria, transforming a large amount of customer supplied guidelines into a solidly defined set of requirement definitions. Thus, one could state with confidence that modern aerospace system design is a Multiple Criteria Decision Making (MCDM) process. A variety of existing decision making methods are available to deal with this type of decision problems. The selection of the most appropriate decision making method is of particular importance since inappropriate decision methods are likely causes of misleading engineering design decisions. With no sufficient knowledge about each of the methods, it is usually difficult for the DMs to find an appropriate analytical model capable of solving their problems. In addition, with the complexity of the decision problem and the demand for more capable methods increasing, new decision making methods are emerging with time. These various methods exacerbate the difficulty of the selection of an appropriate decision making method. Furthermore, some DMs may be exclusively using one or two specific methods which they are familiar with or trust and not realizing that they may be inappropriate to handle certain classes of the problems, thus yielding erroneous results. These issues reveal that in order to ensure a good decision a suitable decision method should be chosen before the decision making process proceeds. The first part of this dissertation proposes an MCDM process supported by an intelligent, knowledge-based advisor system referred to as Multi-Criteria Interactive Decision-Making Advisor and Synthesis process (MIDAS), which is able to facilitate the selection of the most appropriate decision making method and which provides insight to the user for fulfilling different preferences. The second part of this dissertation presents an autonomous decision making advisor which is capable of dealing with ever-evolving real time information and making autonomous decisions under uncertain conditions. The advisor encompasses a Markov Decision Process (MDP) formulation which takes uncertainty into account when determines the best action for each system state. (Abstract shortened by UMI.)

Controversies in oncologist-patient communication: a nuanced approach to autonomy, culture, and paternalism.

PubMed

Cherny, Nathan I

2012-01-01

Difficult dialogues with patients facing life-changing decisions are an intrinsic part of oncologic practice and a major source of stress. Having a sophisticated approach to the concepts of autonomy, paternalism, and culture can help in addressing difficult dilemmas that arise around the issues of disclosure and decision making. This article addresses some of the most common major challenges in oncologist-patient communication with a nuanced approach to the concepts of autonomy, paternalism, and culture. It introduces the new concept of"voluntary diminished autonomy" and describes the implications this concept has for the consent process. It also attempts to bring clarity to common problems and misconceptions relating to culture, paternalism, and therapeutic privilege as these pertain to the communication practices of oncologists.

Informed consent and moral integrity.

PubMed Central

Gillett, G R

1989-01-01

Informed consent is required for any medical procedure although the situations in which it is given are beset by uncertainties and indeterminacies. These make medicolegal scrutiny of such situations very difficult. Although some people find the decision in the Sidaway case incomprehensible because of its continuing regard for a 'professional practice standard' in informed consent, I will argue that an important fact in many cases is the moral integrity of the doctor concerned and the pattern of his practice. This may provide the only morally principled and legally accessible evidence enabling a correct decision to be made in a difficult case. Although the epistemological significance of a professional practice standard is thereby defended the 'prudent patient standard' for what counts as consent is left intact. PMID:2795625

Beyond PSA: are new prostate cancer biomarkers of potential value to New Zealand doctors?

PubMed

Ng, Lance; Karunasinghe, Nishi; Benjamin, Challaraj S; Ferguson, Lynnette R

2012-04-20

The widespread introduction of prostate-specific antigen (PSA) screening has enhanced the early detection of prostate cancer within New Zealand. However, uncertainties associated with the test make it difficult to confidently differentiate low-risk patients from those that require a definitive diagnostic biopsy. In consequence, the decisions surrounding prostate cancer treatment become extremely difficult. A number of new tests have become available which might have the potential to complement the current PSA screens. We review a number of the best validated of these which provide data that, although currently not available in clinical practice, some of these might have considerable potential to aid diagnosis, prognosis and therapeutic decisions for men with prostate cancer in New Zealand.

Decision science: a scientific approach to enhance public health budgeting.

PubMed

Honoré, Peggy A; Fos, Peter J; Smith, Torney; Riley, Michael; Kramarz, Kim

2010-01-01

The allocation of resources for public health programming is a complicated and daunting responsibility. Financial decision-making processes within public health agencies are especially difficult when not supported with techniques for prioritizing and ranking alternatives. This article presents a case study of a decision analysis software model that was applied to the process of identifying funding priorities for public health services in the Spokane Regional Health District. Results on the use of this decision support system provide insights into how decision science models, which have been used for decades in business and industry, can be successfully applied to public health budgeting as a means of strengthening agency financial management processes.

Decision Making: from Neuroscience to Psychiatry

PubMed Central

Lee, Daeyeol

2013-01-01

Adaptive behaviors increase the likelihood of survival and reproduction and improve the quality of life. However, it is often difficult to identify optimal behaviors in real life due to the complexity of the decision maker’s environment and social dynamics. As a result, although many different brain areas and circuits are involved in decision making, evolutionary and learning solutions adopted by individual decision makers sometimes produce suboptimal outcomes. Although these problems are exacerbated in numerous neurological and psychiatric disorders, their underlying neurobiological causes remain incompletely understood. In this review, theoretical frameworks in economics and machine learning and their applications in recent behavioral and neurobiological studies are summarized. Examples of such applications in clinical domains are also discussed for substance abuse, Parkinson’s disease, attention-deficit/hyperactivity disorder, schizophrenia, mood disorders, and autism. Findings from these studies have begun to lay the foundations necessary to improve diagnostics and treatment for various neurological and psychiatric disorders. PMID:23622061

Effects of cigarette smoking on lexical decision-making.

PubMed

Hale, C R; Gentry, M V; Meliska, C J

1999-02-01

10 habitual smokers, aged 19-25 yr., were randomly assigned to smoke either a very low nicotine "Placebo" cigarette (.05-mg nicotine delivery as estimated by the FTC method) or a Nicotine cigarette (.7-mg estimated nicotine delivery). Each participant was asked to abstain from smoking for 4 to 7 hr. prior to testing. After completing a presmoking test of lexical decision-making, participants smoked either a Nicotine or Placebo cigarette and were then retested for reaction times and accuracy on the lexical decision test. When presented the most difficult lexical decisions, participants responded significantly faster after smoking a Nicotine cigarette than they did before smoking; smoking a Placebo cigarette did not affect reaction times. Response accuracy was unaffected by smoking either kind of cigarette. These results suggest that smoking a nicotine cigarette may improve attention or memory retrieval after several hours of smoking abstinence.

Clinical decision rules, spinal pain classification and prediction of treatment outcome: A discussion of recent reports in the rehabilitation literature

PubMed Central

2012-01-01

Clinical decision rules are an increasingly common presence in the biomedical literature and represent one strategy of enhancing clinical-decision making with the goal of improving the efficiency and effectiveness of healthcare delivery. In the context of rehabilitation research, clinical decision rules have been predominantly aimed at classifying patients by predicting their treatment response to specific therapies. Traditionally, recommendations for developing clinical decision rules propose a multistep process (derivation, validation, impact analysis) using defined methodology. Research efforts aimed at developing a “diagnosis-based clinical decision rule” have departed from this convention. Recent publications in this line of research have used the modified terminology “diagnosis-based clinical decision guide.” Modifications to terminology and methodology surrounding clinical decision rules can make it more difficult for clinicians to recognize the level of evidence associated with a decision rule and understand how this evidence should be implemented to inform patient care. We provide a brief overview of clinical decision rule development in the context of the rehabilitation literature and two specific papers recently published in Chiropractic and Manual Therapies. PMID:22726639

Sequential decision making in computational sustainability via adaptive submodularity

USGS Publications Warehouse

Krause, Andreas; Golovin, Daniel; Converse, Sarah J.

2015-01-01

Many problems in computational sustainability require making a sequence of decisions in complex, uncertain environments. Such problems are generally notoriously difficult. In this article, we review the recently discovered notion of adaptive submodularity, an intuitive diminishing returns condition that generalizes the classical notion of submodular set functions to sequential decision problems. Problems exhibiting the adaptive submodularity property can be efficiently and provably near-optimally solved using simple myopic policies. We illustrate this concept in several case studies of interest in computational sustainability: First, we demonstrate how it can be used to efficiently plan for resolving uncertainty in adaptive management scenarios. Secondly, we show how it applies to dynamic conservation planning for protecting endangered species, a case study carried out in collaboration with the US Geological Survey and the US Fish and Wildlife Service.

Multi-Criteria Decision Making For Determining A Simple Model of Supplier Selection

NASA Astrophysics Data System (ADS)

Harwati

2017-06-01

Supplier selection is a decision with many criteria. Supplier selection model usually involves more than five main criteria and more than 10 sub-criteria. In fact many model includes more than 20 criteria. Too many criteria involved in supplier selection models sometimes make it difficult to apply in many companies. This research focuses on designing supplier selection that easy and simple to be applied in the company. Analytical Hierarchy Process (AHP) is used to weighting criteria. The analysis results there are four criteria that are easy and simple can be used to select suppliers: Price (weight 0.4) shipment (weight 0.3), quality (weight 0.2) and services (weight 0.1). A real case simulation shows that simple model provides the same decision with a more complex model.

The attitudes of neonatal nurses towards extremely preterm infants.

PubMed

Gallagher, Katie; Marlow, Neil; Edgley, Alison; Porock, Davina

2012-08-01

The paper is a report of a study of the attitudes of neonatal nurses towards extremely preterm infants. Alongside advancing survival at extremely preterm gestational ages, ethical debates concerning the provision of invasive care have proliferated in light of the high morbidity. Despite nurses being the healthcare professionals who work closest with the infant and their family, their potential influence is usually ignored when determining how parents come to decisions about future care for their extremely premature infant. A Q methodology was employed to explore the attitudes of neonatal nurses towards caring for extremely preterm infants. Data were collected between 2007 and 2008 and analysed using PQMethod and Card Content Analysis. Thirty-six nurses from six neonatal units in the United Kingdom participated. Although there was consensus around the professional role of the nurse, when faced with the complexities of neonatal nursing three distinguishing factors emerged: the importance of parental choice in decision-making, the belief that technology should be used to assess response to treatment, and the belief that healthcare professionals should undertake difficult decisions. Neonatal nurses report unexpected difficulties in upholding their professionally defined role through highly complex and ever varied decision-making processes. Recognition of individual attitudes to the care of extremely preterm infants and the role of the family in the face of difficult decisions should facilitate more open communication between the nurse and the parents and improve the experience of both the nurse and the family during these emotional situations. © 2011 Blackwell Publishing Ltd.

"Higher Education: Factors Lenders Consider in Making Lending Decisions for Private Education Loans." Report to Congressional Committees. GAO-10-86R

ERIC Educational Resources Information Center

Scott, George A.

2009-01-01

Over the past few decades, the cost of tuition, room, and board for undergraduate students has increased, making it more difficult for some students and families to afford the cost of college. While students have historically relied on federal loans and grants and family contributions to pay for college, a growing number have turned to private…

Technology Infusion Challenges from a Decision Support Perspective

NASA Technical Reports Server (NTRS)

Adumitroaie, V.; Weisbin, C. R.

2009-01-01

In a restricted science budget environment and increasingly numerous required technology developments, the technology investment decisions within NASA are objectively more and more difficult to make such that the end results are satisfying the technical objectives and all the organizational constraints. Under these conditions it is rationally desirable to build an investment portfolio, which has the highest possible technology infusion rate. Arguably the path to infusion is subject to many influencing factors, but here only the challenges associated with the very initial stages are addressed: defining the needs and the subsequent investment decision-support process. It is conceivable that decision consistency and possibly its quality suffer when the decision-making process has limited or no traceability. This paper presents a structured decision-support framework aiming to provide traceable, auditable, infusion- driven recommendations towards a selection process in which these recommendations are used as reference points in further discussions among stakeholders. In this framework addressing well-defined requirements, different measures of success can be defined based on traceability to specific selection criteria. As a direct result, even by using simplified decision models the likelihood of infusion can be probed and consequently improved.

To Remodel or To Build?

ERIC Educational Resources Information Center

Rosenblum, Todd

2009-01-01

The question of remodeling an existing house to make it wheelchair accessible or building a new barrier-free house is a difficult decision. This article presents some initial questions and considerations followed by a list of pros and cons for remodeling an existing house vs. building a new house.

Developing Pathways to Serving Together: Military Family Life Course and Decision-Making of Dual Military Couples

DTIC Science & Technology

2010-01-01

common theme for couples in their parent role. Many couples expect it to be emotionally difficult to leave their children for deployments but find it...and going which again is a career timing issue. Parents feel it will be emotionally and mentally difficult for the children to adapt to having...or command when parents have to come to work later of leave earlier because of daycare hours. Stephanie explains her negative reaction from peers

What does the new breed of decision-making methodologies mean for choices and norms in hydrological science?

NASA Astrophysics Data System (ADS)

Wikman-Svahn, Per

2013-04-01

Hydrological sciences are increasingly utilized in decision-making contexts that need to manage deep uncertainty, changing conditions and very long-lead times and lifetimes. Traditional optimizing approaches become problematic in such situations. For example, optimizing approaches may underestimate the importance of low probability outcomes, or very uncertain outcomes. Alternative decision-making strategies are therefore increasingly used in hydrological applications, including "bottom-up/top-down", "context-first", "decision-scaling", "assess risk of policy", "robust", "resilient" or "flexible" approaches. These kinds of strategies are typically designed to handle very uncertain and diverse outcomes, and often start from the particular decision-making context, in contrast to more traditional "predict-then-act" or "science first" approaches. Contemporary research in philosophy of science stress the influence of value judgments and norms in scientific assessments. In particular, this literature points out that implicit anticipated applications often influence choices made in scientific assessments. Furthermore, this literature also emphasize that choices made at within scientific assessments have consequences for decision-making later on. One reason is that it is often difficult for decision-makers to see what choices are made and the implications of these choices. Another reason is that information that could be of use for decision-makers are lost at an early stage. For example, the choice to focus on central estimates and not providing assessments on more unlikely outcomes is a choice that has consequences for what outcomes are taken into account in the decision-making process. This paper develops this argument and then analyzes the implications of these new developments for hydrological science. One implication of the increasing use of the new breed of planning strategies is that a broader range of uncertainty in scientific assessments becomes desirable in order to fully benefit from the power of the new decision-making strategies. Another implication is that bayesian probability assessments become more important. Finally, advantages and risks involved in changing scientific assessments in order to anticipate the new decision-making strategies are discussed.

Development of a Spanish-Language Hospice Video.

PubMed

Chung, Kyusuk; Augustin, Frankline; Esparza, Salvador

2017-09-01

The nation faces a persistent issue of delayed access to hospice care. Even though hospice enrollment is considered to be one of the most difficult medical decisions, physician clinics and hospitals lack tools for helping patients/families faced with making decisions about enrollment. Health-care literature lacks discussion of development of decision-making aids in the context of hospice decisions for minority ethnic groups, even though those groups have decisional needs that may differ from those of non-Hispanic whites. To fill the gap, we developed a video of a Latino hospice patient with footages showing how the patient was being taken care of by her family with support from a hospice disciplinary team. A primary objective of this article is to describe how focus groups, existing decision aids, and individual interviews were used to develop and improve a Spanish-language hospice educational video targeting Latino subgroups with linguistic, cultural, and educational barriers. These steps may provide guidelines for developing and revising health-related videos targeting other minority ethnic groups.

Do Proxies for the Neurotransmitter Cortisol Predict Adaptation to Life with Chronic Pain?

NASA Astrophysics Data System (ADS)

Deamond, Wade

Among the numerous difficulties encountered by chronic pain patients, impulsive and dysfunctional decision-making complicate their already difficult life situations yet remains relatively understudied. This study examined a recently published neurobiological decision making model that identifies eight specific neurotransmitters and hormones (Dopamine, Testosterone, Endogenous Opioids Glutamate, Serotonin, Norepinephrine, Cortisol, and GABA) linked to unsound decision making related to cognitive, motivational and emotional dysregulation (Nussbaum et al., 2011) (see Appendix 2). The Perceived Stress Scale (PSS), a proxy for the cortisol element in the pharmacological decision making model was analyzed for the neurotransmitter's relationship to functionality and quality of life in a group of 37 chronic pain patients. Participants were comprised of males and females ranging from 23 to 52 years of age and were classified with respect to levels of adjustment to living with chronic pain based on the Quality of Life Scale (QLS), the Dartmouth WONCA COOP Charts and the Global Assessment of Functioning (GAF). The Iowa Gambling Task (IGT) and Frontal System Behavioral Scale (FSBS) measured decision making related to immediate gratification and daily living respectively. Results suggest that emotional dysregulation, as measured by the PSS is a significant predictor for adaptation to life with chronic pain and the PSS is superior to predicting adaptation to life with chronic pain than reported levels of pain as measured by the McGill Pain Questionnaire.

Canadian Innovations in Siting Hazardous Waste Management Facilities

PubMed

Kuhn; Ballard

1998-07-01

/ Siting hazardous waste facilities is an extremely complex and difficult endeavor. Public aversion to the construction of these facilities in or near their community often results in concerted opposition, referred to as the NIMBY syndrome. For the most part, siting processes do not fail because of inadequate environmental or technical considerations, but because of the adversarial decision-making strategies employed by the proponents. Innovative siting processes used in the provinces of Alberta and Manitoba offer tangible evidence of the successful application of an innovative siting approach based on the principles of decentralization of decision-making authority and full and meaningful public involvement. The purpose of this paper is to evaluate four Canadian siting processes from the perspective of public participation and access to decision-making authority. Examples of siting processes related to hazardous waste management facilities are provided from the provinces of Alberta, Manitoba, British Columbia, and Ontario. Siting has evolved from approaches dominated by top-down decision making to increasing decentralized and pluralistic approaches. Focusing on social and political concerns of potentially affected communities and on the process of decision making itself are fundamental to achieving siting success. In Alberta initially, and later in Manitoba, this new "open approach" to siting has resulted in the construction of the first two comprehensive hazardous waste treatment facilities in Canada.KEY WORDS: Hazardous waste facilities; Siting methodologies; Public participation

Psychological aspects of individualized choice and reproductive autonomy in prenatal screening.

PubMed

Hewison, Jenny

2015-01-01

Probably the main purpose of reproductive technologies is to enable people who choose to do so to avoid the birth of a baby with a disabling condition. However the conditions women want information about and the 'price' they are willing to pay for obtaining that information vary enormously. Individual women have to arrive at their own prenatal testing choices by 'trading off' means and ends in order to resolve the dilemmas facing them. We know very little about how individuals make these trade-offs, so it is difficult to predict how new technologies will affect their choices and preferences. Uptake decisions can be expected to change, especially in the group of women who now are put off by some aspect of the current screening approach, where the avoidance of miscarriage risk may have provided a kind of 'psychological shelter', protecting a lot of people from having to make other decisions. Technologies such as Pre-implantation Genetic Diagnosis may remove a second 'psychological shelter' because they offer the means of avoiding the birth of an affected child without terminating a pregnancy. Even if new technologies will make some decisions easier in terms of their cognitive demands, they will also create new dilemmas and decision making will not necessarily become less stressful in emotional terms. Key challenges concern information and decision-making. © 2014 John Wiley & Sons Ltd.

Value choices and considerations when limiting intensive care treatment: a qualitative study.

PubMed

Halvorsen, K; Førde, R; Nortvedt, P

2009-01-01

To shed light on the values and considerations that affect the decision-making processes and the decisions to limit intensive care treatment. Qualitative methodology with participant observation and in-depth interviews, with an emphasis on eliciting the underlying rationale of the clinicians' actions and choices when limiting treatment. Informants perceived over-treatment in intensive care medicine as a dilemma. One explanation was that the decision-making base was somewhat uncertain, complex and difficult. The informants claimed that those responsible for taking decisions from the admitting ward prolonged futile treatment because they may bear guilt or responsibility for something that had gone wrong during the course of treatment. The assessments of the patient's situation made by physicians from the admitting ward were often more organ-oriented and the expectations were less realistic than those of clinicians in the intensive care unit who frequently had a more balanced and overall perspective. Aspects such as the personality and the speciality of those involved, the culture of the unit and the degree of interdisciplinary cooperation were important issues in the decision-making processes. Under-communicated considerations jeopardise the principle of equal treatment. If intensive care patients are to be ensured equal treatment, strategies for interdisciplinary, transparent and appropriate decision-making processes must be developed in which open and hidden values are rendered visible, power structures disclosed, employees respected and the various perspectives of the treatment given their legitimate place.

To freeze or not to freeze embryos: clarity, confusion and conflict.

PubMed

Goswami, Mohar; Murdoch, Alison P; Haimes, Erica

2015-06-01

Although embryo freezing is a routine clinical practice, there is little contemporary evidence on how couples make the decision to freeze their surplus embryos, or of their perceptions during that time. This article describes a qualitative study of 16 couples who have had in vitro fertilisation (IVF) treatment. The study question was 'What are the personal and social factors that patients consider when deciding whether to freeze embryos?' We show that while the desire for a baby is the dominant drive, couples' views revealed more nuanced and complex considerations in the decision-making process. It was clear that the desire to have a baby influenced couples' decision-making and that they saw freezing as 'part of the process'. However, there were confusions associated with the term 'freezing' related to concerns about the safety of the procedure. Despite being given written information, couples were confused about the practical aspects of embryo freezing, which suggests they were preoccupied with the immediate demands of IVF. Couples expressed ethical conflicts about freezing 'babies'. We hope the findings from this study will inform clinicians and assist them in providing support to couples confronted with this difficult decision-making.

The Role of Psychological Adjustment in the Decision-making Process for Voluntary Termination of Pregnancy

PubMed Central

Sereno, Sara; Leal, Isabel; Maroco, João

2013-01-01

Background This study's objective was to evaluate the role of psychological adjustment in the decision-making process to have an abortion and explore individual variables that might influence this decision. Methods In this cross-sectional study, we sequentially enrolled 150 women who made the decision to voluntarily terminate a pregnancy in Maternity Dr. Alfredo da Costa, in Lisbon, Portugal, between September 2008 and June 2009. The instruments were the Depression, Anxiety and Stress Scale (DASS), Satisfaction with Social Support Scale (SSSS), Emotional Assessment Scale (EAS), Decision Conflict Scale (DCS), and Beliefs and Values Questionnaire (BVQ). We analyzed the data using Student's T-tests, MANOVA, ANOVA, Tukey's post-hoc tests and CATPCA. Statistically significant effects were accepted for p<0.05. Results The participants found the decision difficult and emotionally demanding, although they also identified it as a low conflict decision. The prevailing emotions were sadness, fear and stress; but despite these feelings, the participants remained psychologically adjusted in the moment they decided to have an abortion. The resolution to terminate the pregnancy was essentially shared with supportive people and it was mostly motivated by socio-economic issues. The different beliefs and values found in this sample, and their possible associations are discussed. Conclusion Despite high levels of stress, the women were psychologically adjusted at the time of making the decision to terminate the pregnancy. However, opposing what has been previously reported, the women presented high levels of sadness and fear, showing that this decision was hard to make, triggering disruptive emotions. PMID:24163799

The complex contribution of sociodemographics to decision-making power in gay male couples

PubMed Central

Perry, Nicholas S.; Huebner, David M.; Baucom, Brian R. W.; Hoff, Colleen C.

2016-01-01

Relationship power is an important dyadic construct in close relationships that is associated with relationship health and partner’s individual health. Understanding what predicts power in heterosexual couples has proven difficult, and even less is known about gay couples. Resource models of power posit that demographic characteristics associated with social status (e.g., age, income) confer power within the relationship, which in turn shapes relationship outcomes. We tested this model in a sample of gay male couples (N=566 couples), and extended it by examining race and HIV status. Multilevel modeling was used to test associations between demographic bases of power and decision-making power. We also examined relative associations among demographic bases and decision-making power with relationship satisfaction, given the literature on power imbalances and overall relationship functioning. Results showed that individual income was positively associated with decision-making power, as was participant’s HIV status, with HIV-positive men reporting greater power. Age differences within the relationship interacted with relationship length to predict decision-making power, but not satisfaction. HIV-concordant positive couples were less satisfied than concordant negative couples. Higher power partners were less satisfied than lower power partners. Demographic factors contributing to decision-making power among same-sex male couples appear to share some similarities with heterosexual couples (e.g., income is associated with power), as well as have unique features (e.g., HIV status influences power). However, these same demographics did not reliably predict relationship satisfaction in the manner that existing power theories suggest. Findings indicate important considerations for theories of power among same-sex male couples. PMID:27606937

Surrogate Motherhood and Abortion for Fetal Abnormality.

PubMed

Walker, Ruth; van Zyl, Liezl

2015-10-01

A diagnosis of fetal abnormality presents parents with a difficult - even tragic - moral dilemma. Where this diagnosis is made in the context of surrogate motherhood there is an added difficulty, namely that it is not obvious who should be involved in making decisions about abortion, for the person who would normally have the right to decide - the pregnant woman - does not intend to raise the child. This raises the question: To what extent, if at all, should the intended parents be involved in decision-making? In commercial surrogacy it is thought that as part of the contractual agreement the intended parents acquire the right to make this decision. By contrast, in altruistic surrogacy the pregnant woman retains the right to make these decisions, but the intended parents are free to decide not to adopt the child. We argue that both these strategies are morally unsound, and that the problems encountered serve to highlight more fundamental defects within the commercial and altruistic models, as well as in the legal and institutional frameworks that support them. We argue in favour of the professional model, which acknowledges the rights and responsibilities of both parties and provides a legal and institutional framework that supports good decision-making. In particular, the professional model acknowledges the surrogate's right to decide whether to undergo an abortion, and the intended parents' obligation to accept legal custody of the child. While not solving all the problems that arise in surrogacy, the model provides a framework that supports good decision-making. © 2015 John Wiley & Sons Ltd.

Adaptive decision making in a dynamic environment: a test of a sequential sampling model of relative judgment.

PubMed

Vuckovic, Anita; Kwantes, Peter J; Neal, Andrew

2013-09-01

Research has identified a wide range of factors that influence performance in relative judgment tasks. However, the findings from this research have been inconsistent. Studies have varied with respect to the identification of causal variables and the perceptual and decision-making mechanisms underlying performance. Drawing on the ecological rationality approach, we present a theory of the judgment and decision-making processes involved in a relative judgment task that explains how people judge a stimulus and adapt their decision process to accommodate their own uncertainty associated with those judgments. Undergraduate participants performed a simulated air traffic control conflict detection task. Across two experiments, we systematically manipulated variables known to affect performance. In the first experiment, we manipulated the relative distances of aircraft to a common destination while holding aircraft speeds constant. In a follow-up experiment, we introduced a direct manipulation of relative speed. We then fit a sequential sampling model to the data, and used the best fitting parameters to infer the decision-making processes responsible for performance. Findings were consistent with the theory that people adapt to their own uncertainty by adjusting their criterion and the amount of time they take to collect evidence in order to make a more accurate decision. From a practical perspective, the paper demonstrates that one can use a sequential sampling model to understand performance in a dynamic environment, allowing one to make sense of and interpret complex patterns of empirical findings that would otherwise be difficult to interpret using standard statistical analyses. PsycINFO Database Record (c) 2013 APA, all rights reserved.

Ethical dilemmas concerning decision-making within health care leadership: a systematic literature review.

PubMed

Zydziūnaite, Vilma; Suominen, Tarja; Astedt-Kurki, Päivi; Lepaite, Daiva

2010-01-01

The objective was to describe the research methods and research focuses on ethical dilemmas concerning decision-making within health care leadership. The search was conducted on Medline and PubMed databases (1998-2008). The systematic review included 21 selected articles. The ethical dilemmas concerning decision-making within health care leadership are related to three levels: institutional (particular organization), political and local interface (local governmental structure), and national (professional expertise and system). The terms that are used as adequate to the term of "ethical dilemma" are the following: "continuous balancing," "result of resource allocation," "gap between professional obligations and possibilities," "ethically controversial situation," "concern about interactions," "ethical difficulty," "outcome of medical choices," "concern about society access to health care resources," "ethically difficult/challenging situation," "(the consequence of) ethical concern/ethical issue." In qualitative studies, a semi-structured interview and qualitative content analysis are the most commonly applied methods; in quantitative studies, questionnaire surveys are employed. In the research literature, there is a lack of specification according to professional qualification of health care professionals concerning ethical dilemmas by decision-making within health care management/administration. The research on ethical dilemmas in health care leadership, management, and administration should integrate data about levels at which ethical dilemmas occur and investigate ethical dilemmas as complex phenomena because those are attached to decision-making and specific nuances of health care management/administration. In this article, the presented scientific problem requires extensive scientific discussions and research on ethical dilemmas concerning decision-making within health care leadership at various levels.

Communication and Decision-Making About End-of-Life Care in the Intensive Care Unit.

PubMed

Brooks, Laura Anne; Manias, Elizabeth; Nicholson, Patricia

2017-07-01

Clinicians in the intensive care unit commonly face decisions involving withholding or withdrawing life-sustaining therapy, which present many clinical and ethical challenges. Communication and shared decision-making are key aspects relating to the transition from active treatment to end-of-life care. To explore the experiences and perspectives of nurses and physicians when initiating end-of-life care in the intensive care unit. The study was conducted in a 24-bed intensive care unit in Melbourne, Australia. An interpretative, qualitative inquiry was used, with focus groups as the data collection method. Intensive care nurses and physicians were recruited to participate in a discipline-specific focus group. Focus group discussions were audio-recorded, transcribed, and subjected to thematic data analysis. Five focus groups were conducted; 17 nurses and 11 physicians participated. The key aspects discussed included communication and shared decision-making. Themes related to communication included the timing of end-of-life care discussions and conducting difficult conversations. Implementation and multidisciplinary acceptance of end-of-life care plans and collaborative decisions involving patients and families were themes related to shared decision-making. Effective communication and decision-making practices regarding initiating end-of-life care in the intensive care unit are important. Multidisciplinary implementation and acceptance of end-of-life care plans in the intensive care unit need improvement. Clear organizational processes that support the introduction of nurse and physician end-of-life care leaders are essential to optimize outcomes for patients, family members, and clinicians. ©2017 American Association of Critical-Care Nurses.

Health technology assessment and primary data collection for reducing uncertainty in decision making.

PubMed

Goeree, Ron; Levin, Les; Chandra, Kiran; Bowen, James M; Blackhouse, Gord; Tarride, Jean-Eric; Burke, Natasha; Bischof, Matthias; Xie, Feng; O'Reilly, Daria

2009-05-01

Health care expenditures continue to escalate, and pressures for increased spending will continue. Health care decision makers from publicly financed systems, private insurance companies, or even from individual health care institutions, will continue to be faced with making difficult purchasing, access, and reimbursement decisions. As a result, decision makers are increasingly turning to evidence-based platforms to help control costs and make the most efficient use of existing resources. Most tools used to assist with evidence-based decision making focus on clinical outcomes. Health technology assessment (HTA) is increasing in popularity because it also considers other factors important for decision making, such as cost, social and ethical values, legal issues, and factors such as the feasibility of implementation. In some jurisdictions, HTAs have also been supplemented with primary data collection to help address uncertainty that may still exist after conducting a traditional HTA. The HTA process adopted in Ontario, Canada, is unique in that assessments are also made to determine what primary data research should be conducted and what should be collected in these studies. In this article, concerns with the traditional HTA process are discussed, followed by a description of the HTA process that has been established in Ontario, with a particular focus on the data collection program followed by the Programs for Assessment of Technology in Health Research Institute. An illustrative example is used to show how the Ontario HTA process works and the role value of information analyses plays in addressing decision uncertainty, determining research feasibility, and determining study data collection needs.

Assessment and Treatment of Personality Disorders: A Behavioral Perspective

ERIC Educational Resources Information Center

Nelson-Gray, Rosemery O.; Lootens, Christopher M.; Mitchell, John T.; Robertson, Christopher D.; Hundt, Natalie E.; Kimbrel, Nathan A.

2009-01-01

Personality disorders are complex and highly challenging to treatment providers; yet, for clients with these problems, there exist very few treatment options that have been supported by research. Given the lack of empirically-supported therapies for personality disorders, it can be difficult to make treatment decisions for this population. The…

Fungicide residue identification and discrimination using a conducting polymer electronic-nose

Treesearch

Alphus D. Wilson

2013-01-01

The identification of fungicide residues on crop foliage is necessary to make periodic pest management decisions. The determination of fungicide residue identities currently is difficult and time consuming using conventional chemical analysis methods such as gas chromatography-mass spectroscopy. Different fungicide types produce unique electronic aroma signature...

Hospital Bioethics: A Beginning Knowledge Base for the Neonatal Social Worker.

ERIC Educational Resources Information Center

Silverman, Ed

1992-01-01

Notes that life-saving advances in medicine have created difficult ethical and legal dilemmas for health care professionals. Presents beginning knowledge base for bioethical practice, especially in hospital neonatal units. Outlines key elements of bioethical decision making and examines potential social work role from clinical and organizational…

Differential Diagnosis in Older Adults: Dementia, Depression, and Delirium.

ERIC Educational Resources Information Center

Gintner, Gary G.

1995-01-01

Examines three common disorders, dementia, depression, and delirium, which can be particularly difficult to diagnose in older adults. Presents three aspects that are helpful in making a decision: age-related differences, medical issues that need to be ruled out, and assessment methods particularly useful in the diagnostic process. (JPS)

Would You Rather (WYR), with a Sexual Health Twist!

ERIC Educational Resources Information Center

Rosen, Brittany; McNeill, Elisa Beth; Wilson, Kelly

2014-01-01

Would You Rather (WYR), with a Sexual Health Twist! teaching technique uses two youth games, "Would you rather…" and Twister®, to actively engage students in developing decision-making skills regarding human sexuality. Utilizing the "Would you rather" choices, the teacher provides a short scenario with two difficult choices.…

The Impact of Individual Decision Making on Campus Sustainability Initiatives

ERIC Educational Resources Information Center

Dade, Aurali Ella

2010-01-01

Institutions of Higher Education (IHEs) have increasingly committed to become more sustainable in recent years. Despite this commitment, academic publications in the sustainability field assert that progress has been slower at IHEs than expected and that most IHEs have found sustainability initiatives difficult to implement. Comprehensive…

Keeping Kids Smokefree: Lessons Learned on Community Participation

ERIC Educational Resources Information Center

Charlier, N.; Glover, M.; Robertson, J.

2009-01-01

Community participation in program decision-making and implementation is an ideal that community and academic stakeholders aspire to in participatory research. This ideal, however, can be difficult to achieve. We describe lessons learned about community participation from a quasi-experimental trial aimed at reducing the uptake of smoking among…

Improving Professional Judgments of Risk and Amenability in Juvenile Justice

ERIC Educational Resources Information Center

Mulvey, Edward P.; Iselin, Anne-Marie R.

2008-01-01

The dual requirement to ensure community safety and promote a youthful offender's positive development permeates policy and frames daily practice in juvenile justice. Balancing those two demands, explain Edward Mulvey and Anne-Marie Iselin, requires justice system professionals at all levels to make extremely difficult decisions about the likely…

Developing Materials for Deliberative Forums

ERIC Educational Resources Information Center

Rourke, Brad

2014-01-01

When citizens deliberate together about important issues, they can reach decisions and take action together on problems that confront them. Deliberation does not require a certain kind of guide, or framework, or language, or facilitator, but, because it can be difficult to face such choices, supporting materials can make it easier. In Developing…

The Principal and the Pear Tree.

ERIC Educational Resources Information Center

Hoyle, John R.

1991-01-01

School principals are in a difficult environment filled with stress and plagued by weak support. Most principals are unprepared for site-based decision making. University professors must take the initiative to use the emerging knowledge base and develop professional studies degree and staff development programs to prepare principals. (24…

Developing Intuitive Reasoning with Graphs to Support Science Arguments

ERIC Educational Resources Information Center

Grueber, David

2011-01-01

Graphs are important for supporting critical thinking and scientific argumentation because students can use them to reason, make judgments and decisions, and solve problems like a scientist (Connery 2007). Yet teaching students how to use math to actually think critically continues to be difficult for teachers. This article describes two…

Sea Stories: A Collaborative Tool for Articulating Tactical Knowledge.

ERIC Educational Resources Information Center

Radtke, Paul H.; Frey, Paul R.

Having subject matter experts (SMEs) identify the skills and knowledge to be taught is among the more difficult and time-consuming steps in the training development process. A procedure has been developed for identifying specific tactical decision-making knowledge requirements and translating SME knowledge into appropriate multimedia…

Leaders' Perceptions of Mobile Technology in the Workplace

ERIC Educational Resources Information Center

Wood, Kristin R.

2012-01-01

Leaders have limited understanding regarding mobile technology (Ramo & Edenius, 2008). However, with over 1 billion users (Meeker, Devitt & Wu, 2011), managers are tasked with making leadership decisions regarding technology adoption, management and use. Leaders may find this difficult to undertake given the limited body of knowledge in…

Theory-informed design of values clarification methods: a cognitive psychological perspective on patient health-related decision making.

PubMed

Pieterse, Arwen H; de Vries, Marieke; Kunneman, Marleen; Stiggelbout, Anne M; Feldman-Stewart, Deb

2013-01-01

Healthcare decisions, particularly those involving weighing benefits and harms that may significantly affect quality and/or length of life, should reflect patients' preferences. To support patients in making choices, patient decision aids and values clarification methods (VCM) in particular have been developed. VCM intend to help patients to determine the aspects of the choices that are important to their selection of a preferred option. Several types of VCM exist. However, they are often designed without clear reference to theory, which makes it difficult for their development to be systematic and internally coherent. Our goal was to provide theory-informed recommendations for the design of VCM. Process theories of decision making specify components of decision processes, thus, identify particular processes that VCM could aim to facilitate. We conducted a review of the MEDLINE and PsycINFO databases and of references to theories included in retrieved papers, to identify process theories of decision making. We selected a theory if (a) it fulfilled criteria for a process theory; (b) provided a coherent description of the whole process of decision making; and (c) empirical evidence supports at least some of its postulates. Four theories met our criteria: Image Theory, Differentiation and Consolidation theory, Parallel Constraint Satisfaction theory, and Fuzzy-trace Theory. Based on these, we propose that VCM should: help optimize mental representations; encourage considering all potentially appropriate options; delay selection of an initially favoured option; facilitate the retrieval of relevant values from memory; facilitate the comparison of options and their attributes; and offer time to decide. In conclusion, our theory-based design recommendations are explicit and transparent, providing an opportunity to test each in a systematic manner. Copyright © 2012 Elsevier Ltd. All rights reserved.

A Pilot Study of Neonatologists' Decision-Making Roles in Delivery Room Resuscitation Counseling for Periviable Births.

PubMed

Tucker Edmonds, Brownsyne; McKenzie, Fatima; Panoch, Janet E; White, Douglas B; Barnato, Amber E

2016-07-01

Relatively little is known about neonatologists' roles in helping families navigate the difficult decision to attempt or withhold resuscitation for a neonate delivering at the threshold of viability. Therefore, we aimed to describe the "decision-making role" of neonatologists in simulated periviable counseling sessions. We conducted a qualitative content analysis of audio-recorded simulation encounters and post-encounter debriefing interviews collected as part of a single-center simulation study of neonatologists' resuscitation counseling practices in the face of ruptured membranes at 23 weeks gestation. We trained standardized patients to request a recommendation if the physician presented multiple treatment options. We coded each encounter for communication behaviors, applying an adapted, previously developed coding scheme to classify physicians into four decision-making roles (informative, facilitative, collaborative, or directive). We also coded post-simulation debriefing interviews for responses to the open-ended prompt: "During this encounter, what did you feel was your role in the management decision-making process?" Fifteen neonatologists (33% of the division) participated in the study; audio-recorded debriefing interviews were available for 13. We observed 9 (60%) take an informative role, providing medical information only; 2 (13%) take a facilitative role, additionally eliciting the patient's values; 3 (20%) take a collaborative role, additionally engaging the patient in deliberation and providing a recommendation; and 1 (7%) take a directive role, making a treatment decision independent of the patient. Almost all (10/13, 77%) of the neonatologists described their intended role as informative. Neonatologists did not routinely elicit preferences, engage in deliberation, or provide treatment recommendations-even in response to requests for recommendations. These findings suggest there may be a gap between policy recommendations calling for shared decision making and actual clinical practice.

Interoceptive Awareness, Positive Affect, and Decision Making in Major Depressive Disorder

PubMed Central

Furman, Daniella J.; Waugh, Christian E.; Bhattacharjee, Kalpa; Thompson, Renee J.; Gotlib, Ian H.

2013-01-01

Background Little work has examined the relation between interoceptive awareness and symptoms of Major Depressive Disorder (MDD). Existing research suggests that depressed individuals exhibit impaired heartbeat perception, though the results of this research have been equivocal. Importantly, depressed participants in these studies have had comorbid anxiety disorders, making it difficult to draw inferences about interoceptive awareness in MDD. The current study addresses this issue by assessing heartbeat perception in depressed women without current anxiety disorders and exploring the relation between interoception and perturbations in both affective intensity and decision making, components of MDD postulated to be related to bodily awareness. Methods Depressed women without concurrent anxiety disorders (n=25) and never-disordered controls (n=36) performed a heartbeat perception task. Participants completed the self-report Affect Intensity Measure (AIM), and decision-making difficulty was assessed in MDD participants using the Structured Clinical Interview for DSM-IV. Results Depressed women exhibited poorer heartbeat perception accuracy than did control participants. Impaired accuracy in MDD participants was associated with reduced positive affectivity and difficulty in decision making. Limitations Our sample was composed exclusively of females and was heterogeneous with respect to treatment status, thereby limiting our ability to generalize results to depressed males and to exclude the contribution of exogenous factors to the observed group differences. Conclusions Results of this study suggest that for depressed individuals without anxiety comorbidities, disrupted perception of bodily responses reduces both the experience of positive arousal and the ability to use interoceptive feedback to inform decision making. PMID:23972662

Dissociable contributions of anterior cingulate cortex and basolateral amygdala on a rodent cost/benefit decision-making task of cognitive effort.

PubMed

Hosking, Jay G; Cocker, Paul J; Winstanley, Catharine A

2014-06-01

Personal success often requires the choice to expend greater effort for larger rewards, and deficits in such effortful decision making accompany a number of illnesses including depression, schizophrenia, and attention-deficit/hyperactivity disorder. Animal models have implicated brain regions such as the basolateral amygdala (BLA) and anterior cingulate cortex (ACC) in physical effort-based choice, but disentangling the unique contributions of these two regions has proven difficult, and effort demands in industrialized society are predominantly cognitive in nature. Here we utilize the rodent cognitive effort task (rCET), a modification of the five-choice serial reaction-time task, wherein animals can choose to expend greater visuospatial attention to obtain larger sucrose rewards. Temporary inactivation (via baclofen-muscimol) of BLA and ACC showed dissociable effects: BLA inactivation caused hard-working rats to 'slack off' and 'slacker' rats to work harder, whereas ACC inactivation caused all animals to reduce willingness to expend mental effort. Furthermore, BLA inactivation increased the time needed to make choices, whereas ACC inactivation increased motor impulsivity. These data illuminate unique contributions of BLA and ACC to effort-based decision making, and imply overlapping yet distinct circuitry for cognitive vs physical effort. Our understanding of effortful decision making may therefore require expanding our models beyond purely physical costs.

Data warehousing as a healthcare business solution.

PubMed

Scheese, R

1998-02-01

Because of the trend toward consolidation in the healthcare field, many organizations have massive amounts of data stored in various information systems organizationwide, but access to the data by end users may be difficult. Healthcare organizations are being pressured to provide managers easy access to the data needed for critical decision making. One solution many organizations are turning to is implementing decision-support data warehouses. A data warehouse instantly delivers information directly to end users, freeing healthcare information systems staff for strategic operations. If designed appropriately, data warehouses can be a cost-effective tool for business analysis and decision support.

Regulating Emotions during Difficult Multiattribute Decision Making: The Role of Pre-Decisional Coherence Shifting.

PubMed

Carpenter, Stephanie M; Yates, J Frank; Preston, Stephanie D; Chen, Lydia

2016-01-01

Almost all real-life decisions entail attribute conflict; every serious choice alternative is better than its competitors on some attribute dimensions but worse on others. In pre-decisional "coherence shifting," the decision maker gradually softens that conflict psychologically to the point where one alternative is seen as dominant over its competitors, or nearly so. Specifically, weaknesses of the eventually chosen alternative come to be perceived as less severe and less important while its strengths seem more desirable and significant. The research described here demonstrates that difficult multiattribute decision problems are aversive and that pre-decisional coherence shifting aids individuals in regulating that emotional discomfort. Across three studies, attribute conflict was confirmed to be aversive (Study 1), and skin conductance responses and ratings of decision difficulty both decreased in participants who coherence shifted (Study 2). Coherence shifting was also diminished among decision makers who were depleted of regulatory resources, known to be required for common emotion regulation mechanisms. Further, coherence shifting was shown to be relatively common among people who reported strong suppression tendencies in everyday emotion regulation (Study 3). Overall, the data suggest that, at least in part, coherence shifting serves as a tool that helps decision makers manage the pre-decisional discomfort generated by attribute conflict. Theoretical and practical implications are discussed.

Regulating Emotions during Difficult Multiattribute Decision Making: The Role of Pre-Decisional Coherence Shifting

PubMed Central

Carpenter, Stephanie M.; Yates, J. Frank; Preston, Stephanie D.; Chen, Lydia

2016-01-01

Almost all real-life decisions entail attribute conflict; every serious choice alternative is better than its competitors on some attribute dimensions but worse on others. In pre-decisional “coherence shifting,” the decision maker gradually softens that conflict psychologically to the point where one alternative is seen as dominant over its competitors, or nearly so. Specifically, weaknesses of the eventually chosen alternative come to be perceived as less severe and less important while its strengths seem more desirable and significant. The research described here demonstrates that difficult multiattribute decision problems are aversive and that pre-decisional coherence shifting aids individuals in regulating that emotional discomfort. Across three studies, attribute conflict was confirmed to be aversive (Study 1), and skin conductance responses and ratings of decision difficulty both decreased in participants who coherence shifted (Study 2). Coherence shifting was also diminished among decision makers who were depleted of regulatory resources, known to be required for common emotion regulation mechanisms. Further, coherence shifting was shown to be relatively common among people who reported strong suppression tendencies in everyday emotion regulation (Study 3). Overall, the data suggest that, at least in part, coherence shifting serves as a tool that helps decision makers manage the pre-decisional discomfort generated by attribute conflict. Theoretical and practical implications are discussed. PMID:26986752

Perceptual decision making: drift-diffusion model is equivalent to a Bayesian model

PubMed Central

Bitzer, Sebastian; Park, Hame; Blankenburg, Felix; Kiebel, Stefan J.

2014-01-01

Behavioral data obtained with perceptual decision making experiments are typically analyzed with the drift-diffusion model. This parsimonious model accumulates noisy pieces of evidence toward a decision bound to explain the accuracy and reaction times of subjects. Recently, Bayesian models have been proposed to explain how the brain extracts information from noisy input as typically presented in perceptual decision making tasks. It has long been known that the drift-diffusion model is tightly linked with such functional Bayesian models but the precise relationship of the two mechanisms was never made explicit. Using a Bayesian model, we derived the equations which relate parameter values between these models. In practice we show that this equivalence is useful when fitting multi-subject data. We further show that the Bayesian model suggests different decision variables which all predict equal responses and discuss how these may be discriminated based on neural correlates of accumulated evidence. In addition, we discuss extensions to the Bayesian model which would be difficult to derive for the drift-diffusion model. We suggest that these and other extensions may be highly useful for deriving new experiments which test novel hypotheses. PMID:24616689

Considering Information Up-to-Dateness to Increase the Accuracy of Therapy Decision Support Systems.

PubMed

Gaebel, Jan; Cypko, Mario A; Oeltze-Jafra, Steffen

2017-01-01

During the diagnostic process a lot of information is generated. All this information is assessed when making a final diagnosis and planning the therapy. While some patient information is stable, e.g., gender, others may become outdated, e.g., tumor size derived from CT data. Quantifying this information up-to-dateness and deriving consequences are difficult. Especially for the implementation in clinical decision support systems, this has not been studied. When information entities tend to become outdated, in practice, clinicians intuitively reduce their impact when making decisions. Therefore, in a system's calculations their impact should be reduced as well. We propose a method of decreasing the certainty of information entities based on their up-to-dateness. The method is tested in a decision support system for TNM staging based on Bayesian networks. We compared the actual N-state in records of 39 patients to the N-state calculated with and without decreasing data certainty. The results under decreased certainty correlated better with the actual states (r=0.958, p=0.008). We conclude that the up-to-dateness must be considered when processing clinical information to enhance decision making and ensure more patient safety.

Use of the AHP methodology in system dynamics: Modelling and simulation for health technology assessments to determine the correct prosthesis choice for hernia diseases.

PubMed

Improta, Giovanni; Russo, Mario Alessandro; Triassi, Maria; Converso, Giuseppe; Murino, Teresa; Santillo, Liberatina Carmela

2018-05-01

Health technology assessments (HTAs) are often difficult to conduct because of the decisive procedures of the HTA algorithm, which are often complex and not easy to apply. Thus, their use is not always convenient or possible for the assessment of technical requests requiring a multidisciplinary approach. This paper aims to address this issue through a multi-criteria analysis focusing on the analytic hierarchy process (AHP). This methodology allows the decision maker to analyse and evaluate different alternatives and monitor their impact on different actors during the decision-making process. However, the multi-criteria analysis is implemented through a simulation model to overcome the limitations of the AHP methodology. Simulations help decision-makers to make an appropriate decision and avoid unnecessary and costly attempts. Finally, a decision problem regarding the evaluation of two health technologies, namely, the evaluation of two biological prostheses for incisional infected hernias, will be analysed to assess the effectiveness of the model. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Decision-making for destination therapy left ventricular assist devices: implications for caregivers.

PubMed

McIlvennan, Colleen K; Jones, Jacqueline; Allen, Larry A; Lindenfeld, JoAnn; Swetz, Keith M; Nowels, Carolyn; Matlock, Daniel D

2015-03-01

Implanting centers often require the identification of a dedicated caregiver before destination therapy left ventricular assist device (DT LVAD) implantation; however, the caregiver experience surrounding this difficult decision is relatively unexplored. From October 2012 through July 2013, we conducted semistructured, in-depth interviews with caregivers of patients considering DT LVAD. Data were analyzed using a mixed inductive and deductive approach. We interviewed 17 caregivers: 10 caregivers of patients living with DT LVAD, 6 caregivers of patients who had died with DT LVAD, and 1 caregiver of a patient who had declined DT LVAD. The themes identified, which could also be considered dialectical tensions, are broadly interpreted under 3 domains mapping to decision context, process, and outcome: (1) the stark decision context, with tension between hope and reality; (2) the challenging decision process, with tension between wanting loved ones to live and wanting to respect loved ones' wishes; and (3) the downstream decision outcome, with tension between gratitude and burden. Decision-making surrounding DT LVAD should incorporate decision support for patients and caregivers. This should include a focus on caregiver burden and the predictable tensions that caregivers experience. © 2015 American Heart Association, Inc.

Evaluation of a rule base for decision making in general practice.

PubMed Central

Essex, B; Healy, M

1994-01-01

BACKGROUND. Decision making in general practice relies heavily on judgmental expertise. It should be possible to codify this expertise into rules and principles. AIM. A study was undertaken to evaluate the effectiveness, of rules from a rule base designed to improve students' and trainees' management decisions relating to patients seen in general practice. METHOD. The rule base was developed after studying decisions about and management of thousands of patients seen in one general practice over an eight year period. Vignettes were presented to 93 fourth year medical students and 179 general practitioner trainees. They recorded their perception and management of each case before and after being presented with a selection of relevant rules. Participants also commented on their level of agreement with each of the rules provided with the vignettes. A panel of five independent assessors then rated as good, acceptable or poor, the participants' perception and management of each case before and after seeing the rules. RESULTS. Exposure to a few selected rules of thumb improved the problem perception and management decisions of both undergraduates and trainees. The degree of improvement was not related to previous experience or to the stated level of agreement with the proposed rules. The assessors identified difficulties students and trainees experienced in changing their perceptions and management decisions when the rules suggested options they had not considered. CONCLUSION. The rules developed to improve decision making skills in general practice are effective when used with vignettes. The next phase is to transform the rule base into an expert system to train students and doctors to acquire decision making skills. It could also be used to provide decision support when confronted with difficult management decisions in general practice. PMID:8204334

Regoaling: a conceptual model of how parents of children with serious illness change medical care goals

PubMed Central

2014-01-01

Background Parents of seriously ill children participate in making difficult medical decisions for their child. In some cases, parents face situations where their initial goals, such as curing the condition, may have become exceedingly unlikely. While some parents continue to pursue these goals, others relinquish their initial goals and generate new goals such as maintaining the child’s quality of life. We call this process of transitioning from one set of goals to another regoaling. Discussion Regoaling involves factors that either promote or inhibit the regoaling process, including disengagement from goals, reengagement in new goals, positive and negative affect, and hopeful thinking. We examine these factors in the context of parental decision making for a seriously ill child, presenting a dynamic conceptual model of regoaling. This model highlights four research questions that will be empirically tested in an ongoing longitudinal study of medical decision making among parents of children with serious illness. Additionally, we consider potential clinical implications of regoaling for the practice of pediatric palliative care. Summary The psychosocial model of regoaling by parents of children with a serious illness predicts that parents who experience both positive and negative affect and hopeful patterns of thought will be more likely to relinquish one set of goals and pursue a new set of goals. A greater understanding of how parents undergo this transition may enable clinicians to better support them through this difficult process. PMID:24625345

Application of an integrated multi-criteria decision making AHP-TOPSIS methodology for ETL software selection.

PubMed

Hanine, Mohamed; Boutkhoum, Omar; Tikniouine, Abdessadek; Agouti, Tarik

2016-01-01

Actually, a set of ETL software (Extract, Transform and Load) is available to constitute a major investment market. Each ETL uses its own techniques for extracting, transforming and loading data into data warehouse, which makes the task of evaluating ETL software very difficult. However, choosing the right software of ETL is critical to the success or failure of any Business Intelligence project. As there are many impacting factors in the selection of ETL software, the same process is considered as a complex multi-criteria decision making (MCDM) problem. In this study, an application of decision-making methodology that employs the two well-known MCDM techniques, namely Analytic Hierarchy Process (AHP) and Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) methods is designed. In this respect, the aim of using AHP is to analyze the structure of the ETL software selection problem and obtain weights of the selected criteria. Then, TOPSIS technique is used to calculate the alternatives' ratings. An example is given to illustrate the proposed methodology. Finally, a software prototype for demonstrating both methods is implemented.

Using an ecological ethics framework to make decisions about the relocation of wildlife.

PubMed

McCoy, Earl D; Berry, Kristin

2008-12-01

Relocation is an increasingly prominent conservation tool for a variety of wildlife, but the technique also is controversial, even among conservation practitioners. An organized framework for addressing the moral dilemmas often accompanying conservation actions such as relocation has been lacking. Ecological ethics may provide such a framework and appears to be an important step forward in aiding ecological researchers and biodiversity managers to make difficult moral choices. A specific application of this framework can make the reasoning process more transparent and give more emphasis to the strong sentiments about non-human organisms held by many potential users. Providing an example of the application of the framework may also increase the appeal of the reasoning process to ecological researchers and biodiversity managers. Relocation as a conservation action can be accompanied by a variety of moral dilemmas that reflect the interconnection of values, ethical positions, and conservation decisions. A model that is designed to address moral dilemmas arising from relocation of humans provides/demonstrates/illustrates a possible way to apply the ecological ethics framework and to involve practicing conservationists in the overall decision-making process.

Experiencing cancer treatment decision-making in managed care.

PubMed

Wenzel, Jennifer; Shaha, Maya

2008-09-01

This paper is a report of a study to explore women's perceptions of and experiences with breast cancer treatment decision-making in managed care organizations (MCOs). Managed care organizations are the predominant form of employer-sponsored healthcare insurance in the United States of America. These healthcare financing entities minimize cost by streamlining healthcare delivery and may impose choice restrictions. The extent of these restrictions has not previously been studied from an in-depth patient perspective. A qualitative descriptive approach was adopted using interviews with a purposive sample of 14 managed care enrollees diagnosed with breast cancer at all stages. The data were collected between 2003 and 2005. Data analysis involved a reflexive process of transcript reading, categorization, data reduction and interpretation. The findings are presented as a single theme: 'decisional conflict in managed care', with two distinct categories: decisions regarding (1) the MCOs and (2) treatment. MCO selection was perceived to be limited by employer constraints, cost issues or healthcare plan providers. For study participants, selecting a MCO was less difficult than issues surrounding treatment decision-making. Women reported that their most important treatment-related decisions surrounded diagnosis and involved selecting a treatment facility and provider. Once a satisfactory facility and provider were selected, these women preferred to defer treatment decisions to their healthcare providers. Decision interventions should be focused on assisting women with provider and treatment facility selection early in diagnosis. Our findings might also serve as a basis for policy/practice changes to address healthcare financing limitations and to expand cancer treatment-related choices while providing desired treatment decision-making support.

The Supreme Court, abortion, and the jurisprudence of class.

PubMed Central

Mariner, W K

1992-01-01

The US Supreme Court's decision in Planned Parenthood of Southeastern Pennsylvania v Casey both protects a woman's liberty to choose to terminate her pregnancy and permits the state to make it more difficult for her to exercise her choice. In their opinion on the case, Justices O'Connor, Kennedy, and Souter eloquently defend constitutional protection of the right to make intimate decisions like continuing or ending a pregnancy. At the same time, they permit the state to try to persuade pregnant women not to have abortions and to make abortion harder to obtain and more costly, as long as the state's methods do not create an "undue burden" on the decision. Any restriction on abortion is a burden; whether it is "undue" (and therefore unconstitutional) depends on one's circumstances. The Court appears to view the difference between an undue burden and mere inconvenience from the perspective of privilege. The restrictions that were upheld may not significantly affect middle-class access to abortion, but they could prove insurmountable for many less privileged women. PMID:1443311

Developing Digital Dashboard Management for Learning System Dynamic Cooperative Simulation Behavior of Indonesia. (Study on Cooperative Information Organization in the Ministry of Cooperatives and SME)

NASA Astrophysics Data System (ADS)

Eni, Yuli; Aryanto, Rudy

2014-03-01

There are problems being experienced by the Ministry of cooperatives and SME (Small and Medium Enterprise) including the length of time in the decision by the Government to establish a policy that should be taken for local cooperatives across the province of Indonesia. The decision-making process is still analyzed manually, so that sometimes the decisions taken are also less appropriate, effective and efficient. The second problem is the lack of monitoring data cooperative process province that is too much, making it difficult for the analysis of dynamic information to be useful. Therefore the authors want to fix the system that runs by using digital dashboard management system supported by the modeling of system dynamics. In addition, the author also did the design of a system that can support the system. Design of this system is aimed to ease the experts, head, and the government to decide (DSS - Decision Support System) accurately effectively and efficiently, because in the system are raised alternative simulation in a description of the decision to be taken and the result from the decision. The system is expected to be designed dan simulated can ease and expedite the decision making. The design of dynamic digital dashboard management conducted by method of OOAD (Objects Oriented Analysis and Design) complete with UML notation.

Teaching Gender Issues at a Women's College: A Male's Perspective.

ERIC Educational Resources Information Center

Burke, Ken

Testifying to the virtues of teaching at an all-women's college (Mills College, Oakland, California), a male tenured professor of communication and film acknowledges the necessity of making difficult decisions concerning course content and focus. Through several uncomfortable experiences, he has learned what it is like to be gender conscious; he…

Mentoring in the Clinical Setting to Improve Student Decision-Making Competence

ERIC Educational Resources Information Center

Stick-Mueller, Misty; Boesch, Ron; Silverman, Steven; Carpenter, Scott; Illingworth, Robert; Countryman, James

2010-01-01

Introduction: The physician-intern relationship can be difficult to develop. A new chiropractic intern in a teaching clinic undergoes a major transition from classroom to clinical practice and must learn to turn classroom knowledge into clinical application. The ability to start formulating clinical techniques and apply them on a patient is…

Dysphagia Therapy in Stroke: A Survey of Speech and Language Ttherapists

ERIC Educational Resources Information Center

Archer, S. K.; Wellwood, I.; Smith, C. H.; Newham, D. J.

2013-01-01

Background: Dysphagia is common after stroke, leading to adverse outcome. There is a paucity of high-quality evidence for dysphagia therapy, thus making it difficult to determine the best approaches to treatment. Clinical decisions are often based on usual practice, however no formal method of monitoring practice patterns exists. Aims: To…

Attitudes toward Career Counseling: The Role of Public and Self-Stigma

ERIC Educational Resources Information Center

Ludwikowski, Wyndolyn M. A.; Vogel, David; Armstrong, Patrick Ian

2009-01-01

Although many students struggle with career-related issues in college, comparatively few engage the career services offered by their academic institutions for help with their difficulties. In addition, there is little research on the factors influencing students' decisions to engage in counseling for career-related issues, making it difficult to…

Justice. Law in a Free Society Series. Level VI. Second Edition.

ERIC Educational Resources Information Center

Center for Civic Education, Calabasas, CA.

Designed to help high school students, this curriculum guides youngsters to develop a better understanding of difficult issues raised by questions of justice. It is hoped that the ideas, observations, questions, and procedures students learn in the curriculum will help them to make informed decisions about how to promote justice and combat…

Information and knowledge management in support of sustainable forestry: a review

Treesearch

H. Michael Rauscher; Daniel L. Schmoldt; Harald Vacik

2007-01-01

For individuals, organizations and nations, success and even survival depend upon making good decisions. Doing so can be extremely difficult when problems are not well structured and situations are complex, as they are for natural resource management. Recent advances in computer technology coupled with the increase in accessibility brought about by the...

An Enrollment Marketing Plan for Institutions of Higher Learning: An Update.

ERIC Educational Resources Information Center

Bingham, Frank G., Jr.

1996-01-01

A college marketing model consisting of several strategies and contingency plans for decision-making under difficult conditions is outlined. The plan provides for orderly transition from one marketing stage to the next logical stage, allowing some control over both internal and external environments, and providing insight into the delicate…

EcoCity Columbus: Using an Ohio State University Planning Class to Bring Sustainability Concepts to Columbus, Ohio

ERIC Educational Resources Information Center

Conroy, Maria Manta

2004-01-01

Attention in US literature and practice addressing sustainable development has focused on a limited number of communities such as Seattle, Washington, and Portland, Oregon. These communities have been identified as making difficult decisions and ground-breaking policies to advance sustainability initiatives. However, these communities are…

School-based Parents' Groups--A Politics of Voice and Representation?

ERIC Educational Resources Information Center

Vincent, Carol; Martin, Jane

2000-01-01

Considers discussion-based parents' forums at two British secondary schools. Each school has attracted an elite group of white, middle-class professional women with limited decision-making power that remains unconnected to the wider parent body. It is difficult for controversial parental issues to be heard. (Contains 39 references.) (MLH)

Conflicting Pressures That Impinge Upon the Operational Effectiveness of Institutional Researchers: Challenges to the Practitioner.

ERIC Educational Resources Information Center

Gubasta, Joseph L.

The numerous issues and problems facing college and university decisionmakers and the ever increasing information needs of external agency representatives place conflicting pressures on institutional research personnel, forcing them to make difficult decisions regarding the allocation of their resources. Outlined are several such pressures. It is…

Chapter 13: Applying GTR 220 Concepts on the Sagehen Experimental Forest

Treesearch

P. Stine; S. Conway

2012-01-01

Applying science to the practice of forest management is a difficult process. Scientific results tend to be expressed in terms such as variances, confidence intervals, and probability distributions. Rarely does science provide unequivocal information, yet land managers must make definitive decisions on the ground. The General Technical Report "An Ecosystem...

Dare to Share

ERIC Educational Resources Information Center

Briggs, Linda L.

2007-01-01

Today, as difficult as it is for large institutions to keep software and hardware up-to-date, the challenge and expense of keeping up is only amplified for smaller colleges and universities. In the area of data-driven decision-making (DDD), the challenge can be even greater. Because smaller schools are pressed for time and resources on nearly all…

Developing a Benchmark Tool for Sustainable Consumption: An Iterative Process

ERIC Educational Resources Information Center

Heiskanen, E.; Timonen, P.; Nissinen, A.; Gronroos, J.; Honkanen, A.; Katajajuuri, J. -M.; Kettunen, J.; Kurppa, S.; Makinen, T.; Seppala, J.; Silvenius, F.; Virtanen, Y.; Voutilainen, P.

2007-01-01

This article presents the development process of a consumer-oriented, illustrative benchmarking tool enabling consumers to use the results of environmental life cycle assessment (LCA) to make informed decisions. LCA provides a wealth of information on the environmental impacts of products, but its results are very difficult to present concisely…

Development of an Online Hazards Atlas to Improve Disaster Awareness

ERIC Educational Resources Information Center

Battersby, Sarah E.; Mitchell, Jerry T.; Cutter, Susan L.

2011-01-01

Understanding the causes, effects and geographic patterns of local hazards is important for helping individuals make educated decisions about how to respond to their threat. Unfortunately, it is often difficult to find comprehensive sources of information about local hazards. In this paper, we discuss the development of an online hazards atlas for…

Helping Your Children Navigate Their Teenage Years: A Guide for Parents.

ERIC Educational Resources Information Center

Schwebel, Robert

Noting that caring adults can help teens make the right decisions during the difficult time of adolescence, this guide for parents provides some useful tools to improve parents' communication with teenagers to help them get through adolescence successfully. The booklet is presented in six parts: (1) "Getting the Conversation Started," including…

The Decision-Making Process for Families Investing in Higher Education: A Family Systems Perspective

ERIC Educational Resources Information Center

McHugh, Erin M.

2017-01-01

When families consider investing in their children's education they must weigh the perceived costs against the potential benefits, which becomes increasingly difficult as the cost of higher education continues to rise. Using a family systems approach, this phenomenological study explored the central research question, "How do families…

Tough Choices in Difficult Times.

ERIC Educational Resources Information Center

Scheer, Sage Ann

2002-01-01

Key areas school districts have used in making the decision to purchase technology applications include: what the district hopes to achieve by purchasing the system; how the proposed system will support the district's vision and help achieve the strategic plan; what the effect of the proposed solution will be on staffing; and what type of timeline…

[End-of-life decisions and practices in critically ill patients in the cardiac intensive care unit. A nationwide survey].

PubMed

Schimmer, C; Hamouda, K; Oezkur, M; Sommer, S-P; Leistner, M; Leyh, R

2016-03-01

Ethical and medical criteria in the decision-making process of withholding or withdrawal of life support therapy in critically ill patients present a great challenge in intensive care medicine. The purpose of this work was to assess medical and ethical criteria that influence the decision-making process for changing the aim of therapy in critically ill cardiac surgery patients. A questionnaire was distributed to all German cardiac surgery centers (n = 79). All clinical directors, intensive care unit (ICU) consultants and ICU head nurses were asked to complete questionnaires (n = 237). In all, 86 of 237 (36.3 %) questionnaires were returned. Medical reasons which influence the decision-making process for changing the aim of therapy were cranial computed tomography (cCT) with poor prognosis (91.9 %), multi-organ failure (70.9 %), and failure of assist device therapy (69.8 %). Concerning ethical reasons, poor expected quality of life (48.8 %) and the presumed patient's wishes (40.7 %) were reported. There was a significant difference regarding the perception of the three different professional groups concerning medical and ethical criteria as well as the involvement in the decision-making process. In critically ill cardiac surgery patients, medical reasons which influence the decision-making process for changing the aim of therapy included cCT with poor prognosis, multi-organ failure, and failure of assist device therapy. Further studies are mandatory in order to be able to provide adequate answers to this difficult topic.

Dissociation between dorsal and ventral hippocampal theta oscillations during decision-making.

PubMed

Schmidt, Brandy; Hinman, James R; Jacobson, Tara K; Szkudlarek, Emily; Argraves, Melissa; Escabí, Monty A; Markus, Etan J

2013-04-03

Hippocampal theta oscillations are postulated to support mnemonic processes in humans and rodents. Theta oscillations facilitate encoding and spatial navigation, but to date, it has been difficult to dissociate the effects of volitional movement from the cognitive demands of a task. Therefore, we examined whether volitional movement or cognitive demands exerted a greater modulating factor over theta oscillations during decision-making. Given the anatomical, electrophysiological, and functional dissociations along the dorsal-ventral axis, theta oscillations were simultaneously recorded in the dorsal and ventral hippocampus in rats trained to switch between place and motor-response strategies. Stark differences in theta characteristics were found between the dorsal and ventral hippocampus in frequency, power, and coherence. Theta power increased in the dorsal, but decreased in the ventral hippocampus, during the decision-making epoch. Interestingly, the relationship between running speed and theta power was uncoupled during the decision-making epoch, a phenomenon limited to the dorsal hippocampus. Theta frequency increased in both the dorsal and ventral hippocampus during the decision epoch, although this effect was greater in the dorsal hippocampus. Despite these differences, ventral hippocampal theta was responsive to the navigation task; theta frequency, power, and coherence were all affected by cognitive demands. Theta coherence increased within the dorsal hippocampus during the decision-making epoch on all three tasks. However, coherence selectively increased throughout the hippocampus (dorsal to ventral) on the task with new hippocampal learning. Interestingly, most results were consistent across tasks, regardless of hippocampal-dependent learning. These data indicate increased integration and cooperation throughout the hippocampus during information processing.

Can streamlined multi-criteria decision analysis be used to implement shared decision making for colorectal cancer screening?

PubMed Central

Dolan, James G.; Boohaker, Emily; Allison, Jeroan; Imperiale, Thomas F.

2013-01-01

Background Current US colorectal cancer screening guidelines that call for shared decision making regarding the choice among several recommended screening options are difficult to implement. Multi-criteria decision analysis (MCDA) is an established methodology well suited for supporting shared decision making. Our study goal was to determine if a streamlined form of MCDA using rank order based judgments can accurately assess patients’ colorectal cancer screening priorities. Methods We converted priorities for four decision criteria and three sub-criteria regarding colorectal cancer screening obtained from 484 average risk patients using the Analytic Hierarchy Process (AHP) in a prior study into rank order-based priorities using rank order centroids. We compared the two sets of priorities using Spearman rank correlation and non-parametric Bland-Altman limits of agreement analysis. We assessed the differential impact of using the rank order-based versus the AHP-based priorities on the results of a full MCDA comparing three currently recommended colorectal cancer screening strategies. Generalizability of the results was assessed using Monte Carlo simulation. Results Correlations between the two sets of priorities for the seven criteria ranged from 0.55 to 0.92. The proportions of absolute differences between rank order-based and AHP-based priorities that were more than ± 0.15 ranged from 1% to 16%. Differences in the full MCDA results were minimal and the relative rankings of the three screening options were identical more than 88% of the time. The Monte Carlo simulation results were similar. Conclusion Rank order-based MCDA could be a simple, practical way to guide individual decisions and assess population decision priorities regarding colorectal cancer screening strategies. Additional research is warranted to further explore the use of these methods for promoting shared decision making. PMID:24300851

Chinese familial tradition and Western influence: a case study in Singapore on decision making at the end of life.

PubMed

Ho, Zheng Jie Marc; Radha Krishna, Lalit Kumar; Yee, Chung Pheng Alethea

2010-12-01

Decision making for an incompetent patient at the end of life is difficult for both family members and physicians alike. Often, palliative care teams are tasked with weaving through opinions, emotions, and goals in search for an amenable solution. Occasionally, these situations get challenging. We present the case of an elderly Chinese Singaporean with metastatic cancer, whose family and physicians had conflicting goals of care. The former was adamant on treating the patient's disease with an untested drug, whereas the latter aimed to treat his symptoms with more conventional medication. Drug-drug interactions prevented treatment with both. Beginning with a discussion of the patient's best interest, we delve into the Singaporean context to show how culture affects medical decision making. Confucianism and filial piety are the values on which this family's workings were based. In an analysis of what this entails, we attempt to explain the significant and assertive family involvement in the decision-making process and their insistence on using novel medications, having exhausted conventional interventions. Within this mix were Western influences, too. Through the Internet, family members have become more informed and empowered in decision making, wresting the traditional paternalistic role of physicians in favor of "patient autonomy." An understanding of such dynamic facets will help better tailor culturally appropriate approaches to such complex situations. Copyright © 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Cancer screening in the older adult: issues and concerns.

PubMed

Craft, Melissa

2014-06-01

Making individual recommendations for cancer screening in older adult patients may be difficult and time consuming, because of the need to incorporate complex issues of life expectancy, health status, risks and benefits, and individual values and wishes. In this article, current recommendations and related risks and benefits are summarized. Specific issues and concerns are addressed, with suggestions for strategies to assist older adults in making screening decisions. Copyright © 2014 Elsevier Inc. All rights reserved.

[The Intentions Affecting the Medical Decision-Making Behavior of Surrogate Decision Makers of Critically Ill Patients and Related Factors].

PubMed

Su, Szu-Huei; Wu, Li-Min

2018-04-01

The severity of diseases and high mortality rates that typify the intensive care unit often make it difficult for surrogate decision makers to make decisions for critically ill patients regarding whether to continue medical treatments or to accept palliative care. To explore the behavioral intentions that underlie the medical decisions of surrogate decision makers of critically ill patients and the related factors. A cross-sectional, correlation study design was used. A total of 193 surrogate decision makers from six ICUs in a medical center in southern Taiwan were enrolled as participants. Three structured questionnaires were used, including a demographic datasheet, the Family Relationship Scale, and the Behavioral Intention of Medical Decisions Scale. Significantly positive correlations were found between the behavioral intentions underlying medical decisions and the following variables: the relationship of the participant to the patient (Eta = .343, p = .020), the age of the patient (r = .295, p < .01), and whether the patient had signed a currently valid advance healthcare directive (Eta = .223, p = .002). Furthermore, a significantly negative correlation was found between these intentions and length of stay in the ICU (r = -.263, p < .01). Patient age, whether the patient had signed a currently valid advance healthcare directive, and length of stay in the ICU were all predictive factors for the behavioral intentions underlying the medical decisions of the surrogate decision makers, explaining 13.9% of the total variance. In assessing the behavioral intentions underlying the medical decisions of surrogate decision makers, health providers should consider the relationship between critical patients and their surrogate decision makers, patient age, the length of ICU stay, and whether the patient has a pre-signed advance healthcare directive in order to maximize the effectiveness of medical care provided to critically ill patients.

Noradrenergic modulation of vicarious trial-and-error behavior during a spatial decision-making task in rats.

PubMed

Amemiya, S; Noji, T; Kubota, N; Nishijima, T; Kita, I

2014-04-18

Deliberation between possible options before making a decision is crucial to responding with an optimal choice. However, the neural mechanisms regulating this deliberative decision-making process are still unclear. Recent studies have proposed that the locus coeruleus-noradrenaline (LC-NA) system plays a role in attention, behavioral flexibility, and exploration, which contribute to the search for an optimal choice under uncertain situations. In the present study, we examined whether the LC-NA system relates to the deliberative process in a T-maze spatial decision-making task in rats. To quantify deliberation in rats, we recorded vicarious trial-and-error behavior (VTE), which is considered to reflect a deliberative process exploring optimal choices. In experiment 1, we manipulated the difficulty of choice by varying the amount of reward pellets between the two maze arms (0 vs. 4, 1 vs. 3, 2 vs. 2). A difficulty-dependent increase in VTE was accompanied by a reduction of choice bias toward the high reward arm and an increase in time required to select one of the two arms in the more difficult manipulation. In addition, the increase of c-Fos-positive NA neurons in the LC depended on the task difficulty and the amount of c-Fos expression in LC-NA neurons positively correlated with the occurrence of VTE. In experiment 2, we inhibited LC-NA activity by injection of clonidine, an agonist of the alpha2 autoreceptor, during a decision-making task (1 vs. 3). The clonidine injection suppressed occurrence of VTE in the early phase of the task and subsequently impaired a valuable choice later in the task. These results suggest that the LC-NA system regulates the deliberative process during decision-making. Copyright © 2014 IBRO. Published by Elsevier Ltd. All rights reserved.

Factors influencing nurses' judgements about self-neglect cases.

PubMed

Lauder, W; Ludwick, R; Zeller, R; Winchell, J

2006-06-01

From the perspective of the practising nurse self-neglect may best be understood in terms of a set of complex and often poorly defined clinical problems in which two key clinical issues are "how do I judge whether this person has the capacity to make decisions about their lifestyle?" and "do we need to treat this person using mental health legislation?" These are taxing questions as judging if a patient has the capacity to make decisions about their lifestyle choices is difficult for even the most experienced clinicians. Such determinations require nurses to form a judgement as to mental capacity of the patient. We do not know what patient characteristics and in what combination nurses use these when making these judgements. This factorial survey aimed to identify which patient characteristics influenced Registered Nurses' judgements on decision-making capacity and decisions on the use of interventions which require statutory interventions in cases of self-neglect. Judgements on decision-making capacity were overwhelmingly predicted by information of the patients' mental health status. Nurses place patients in one of three broad categories of no mental illness, minor mental illness and severe mental illness. This categorization appears to operate as a fast and frugal heuristic indicating that nurses may use mental status as a cognitive screen to work from in judging self-neglect. Although there is a correlation between the severity of mental illness and the capacity for making decisions they are not the same. This study shows the continued work that needs done in educating nurses not only about self-neglect but also about the role a patient's mental status may have in assessment of problems.

The complex contribution of sociodemographics to decision-making power in gay male couples.

PubMed

Perry, Nicholas S; Huebner, David M; Baucom, Brian R W; Hoff, Colleen C

2016-12-01

Relationship power is an important dyadic construct in close relationships that is associated with relationship health and partner's individual health. Understanding what predicts power in heterosexual couples has proven difficult, and even less is known about gay couples. Resource models of power posit that demographic characteristics associated with social status (e.g., age, income) confer power within the relationship, which in turn shapes relationship outcomes. We tested this model in a sample of gay male couples (N = 566 couples) and extended it by examining race and HIV status. Multilevel modeling was used to test associations between demographic bases of power and decision-making power. We also examined relative associations among demographic bases and decision-making power with relationship satisfaction given the literature on power imbalances and overall relationship functioning. Results showed that individual income was positively associated with decision-making power, as was participant's HIV status, with HIV-positive men reporting greater power. Age differences within the relationship interacted with relationship length to predict decision-making power, but not satisfaction. HIV-concordant positive couples were less satisfied than concordant negative couples. Higher power partners were less satisfied than lower power partners. Demographic factors contributing to decision-making power among same-sex male couples appear to share some similarities with heterosexual couples (e.g., income is associated with power) and have unique features (e.g., HIV status influences power). However, these same demographics did not reliably predict relationship satisfaction in the manner that existing power theories suggest. Findings indicate important considerations for theories of power among same-sex male couples. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

The role of the bioethicist in family meetings about end of life care.

PubMed

Watkins, Liza T; Sacajiu, Galit; Karasz, Alison

2007-12-01

There has been little study of the content of bioethicists' communication during family meeting consultations about end of life care. In the literature, two roles for bioethicists are usually described: the "consultant" role, in which bioethicists define and support ethical principles such as those enshrined in the "rational choice" model; and the "mediator" role, which focuses on the enhancement of communication in order to reduce conflict. In this study, we use observational data to explore how bioethicists support the practice of decision making during family meetings about end of life care. In a study conducted in the Bronx, New York, USA, researchers observed and recorded 24 decision-making meetings between hospital staff and family members of elderly patients identified as being in the last stages of illness, who were unable or unwilling to make the decision for themselves. Bioethics consultants were present during five of those meetings. Although bioethicists referred to the "rational choice" decision-making hierarchy, we did not see the systematic exploration described in the literature. Rather, our data show that bioethicists tended to employ elements of the rational model at particular turning points in the decision-making process in order to achieve pragmatic goals. As mediators, bioethicists worked to create consensus between family and staff and provided invaluable sympathy and comfort to distressed family members. We also found evidence of a context-dependent approach to mediation, with bioethicists' contributions generally supporting staff views about end of life care. Bioethicists' called to consult on family meetings about end of life care do not appear to adhere to a strict interpretation of the official guidelines. In order to negotiate the difficult terrain of end of life decision making, our data show that bioethicists often add a third role, "persuader", to official roles of "consultant" and "mediator".

Clinical decision making in a high-risk primary care environment: a qualitative study in the UK.

PubMed

Balla, John; Heneghan, Carl; Thompson, Matthew; Balla, Margaret

2012-01-01

Examine clinical reasoning and decision making in an out of hours (OOH) primary care setting to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment. Semi-structured interviews using open-ended questions. A 2-month qualitative interview study conducted in Oxfordshire, UK. 21 GPs working in OOH primary care. The most powerful themes to emerge related to dealing with urgent potentially high-risk cases, keeping patients safe and responding to their needs, while trying to keep patients out of hospital and the concept of 'fire fighting'. There were a number of well-defined characteristics that GPs reported making presentations easy or difficult to deal with. Severely ill patients were straightforward, while the older people, with complex multisystem diseases, were often difficult. GPs stopped collecting clinical information and came to clinical decisions when high-risk disease and severe illness requiring hospital attention has been excluded; they had responded directly to the patient's needs and there was a reliable safety net in place. Learning points that GPs identified as important for trainees in the OOH setting included the importance of developing rapport in spite of time pressures, learning to deal with uncertainty and learning about common presentations with a focus on critical cues to exclude severe illness. The findings support suggestions that improvements in primary care OOH could be achieved by including automated and regular timely feedback system for GPs and individual peer and expert clinician support for GPs with regular meetings to discuss recent cases. In addition, trainee support and mentoring to focus on clinical skills, knowledge and risk management issues specific to OOH is currently required. Investigating the stopping rules used for diagnostic closure may provide new insights into the root causes of clinical error in such a high-risk setting.

Participation in health impact assessment: objectives, methods and core values.

PubMed

Wright, John; Parry, Jayne; Mathers, Jonathan

2005-01-01

Health impact assessment (HIA) is a multidisciplinary aid to decision-making that assesses the impact of policy on public health and on health inequalities. Its purpose is to assist decision-makers to maximize health gains and to reduce inequalities. The 1999 Gothenburg Consensus Paper (GCP) provides researchers with a rationale for establishing community participation as a core value of HIA. According to the GCP, participation in HIA empowers people within the decision-making process and redresses the democratic deficit between government and society. Participation in HIA generates a sense that health and decision-making is community-owned, and the personal experiences of citizens become integral to the formulation of policy. However, the participatory and empowering dimensions of HIA may prove difficult to operationalize. In this review of the participation strategies adopted in key applications of HIA in the United Kingdom, we found that HIA's aim of influencing decision-making creates tension between its participatory and knowledge-gathering dimensions. Accordingly, researchers have decreased the participatory dimension of HIA by reducing the importance attached to the community's experience of empowerment, ownership and democracy, while enlarging its knowledge-gathering dimension by giving pre-eminence to "expert" and "research-generated" evidence. Recent applications of HIA offer a serviceable rationale for participation as a means of information gathering and it is no longer tenable to uphold HIA as a means of empowering communities and advancing the aims of participatory democracy.

Participation in health impact assessment: objectives, methods and core values.

PubMed Central

Wright, John; Parry, Jayne; Mathers, Jonathan

2005-01-01

Health impact assessment (HIA) is a multidisciplinary aid to decision-making that assesses the impact of policy on public health and on health inequalities. Its purpose is to assist decision-makers to maximize health gains and to reduce inequalities. The 1999 Gothenburg Consensus Paper (GCP) provides researchers with a rationale for establishing community participation as a core value of HIA. According to the GCP, participation in HIA empowers people within the decision-making process and redresses the democratic deficit between government and society. Participation in HIA generates a sense that health and decision-making is community-owned, and the personal experiences of citizens become integral to the formulation of policy. However, the participatory and empowering dimensions of HIA may prove difficult to operationalize. In this review of the participation strategies adopted in key applications of HIA in the United Kingdom, we found that HIA's aim of influencing decision-making creates tension between its participatory and knowledge-gathering dimensions. Accordingly, researchers have decreased the participatory dimension of HIA by reducing the importance attached to the community's experience of empowerment, ownership and democracy, while enlarging its knowledge-gathering dimension by giving pre-eminence to "expert" and "research-generated" evidence. Recent applications of HIA offer a serviceable rationale for participation as a means of information gathering and it is no longer tenable to uphold HIA as a means of empowering communities and advancing the aims of participatory democracy. PMID:15682250

Evolution of a CDC Public Health Research Agenda for Low-Risk Prostate Cancer

PubMed Central

Hall, Ingrid J.; Smith, Judith Lee

2016-01-01

Men with prostate cancer face difficult choices when selecting a therapy for localized prostate cancer. Comparative data from controlled studies are lacking and clinical opinions diverge about the benefits and harms of treatment options. Consequently, there is limited guidance for patients regarding the impact of treatment decisions on quality of life. There are opportunities for public health to intervene at several decision-making points. Information on typical quality of life outcomes associated with specific prostate cancer treatments could help patients select treatment options. From 2003 to present, the Division of Cancer Prevention and Control at CDC has supported projects to explore patient information-seeking behavior post-diagnosis, caregiver and provider involvement in treatment decision making, and patient quality of life following prostate cancer treatment. CDC's work also includes research that explores barriers and facilitators to the presentation of active surveillance as a viable treatment option and promotes equal access to information for men and their caregivers. This article provides an overview of the literature and considerations that initiated establishing a prospective public health research agenda around treatment decision making. Insights gathered from CDC-supported studies are poised to enhance understanding of the process of shared decision making and the influence of patient, caregiver, and provider preferences on the selection of treatment choices. These findings provide guidance about attributes that maximize patient experiences in survivorship, including optimal quality of life and patient and caregiver satisfaction with information, treatment decisions, and subsequent care. PMID:26590643

Voting systems for environmental decisions.

PubMed

Burgman, Mark A; Regan, Helen M; Maguire, Lynn A; Colyvan, Mark; Justus, James; Martin, Tara G; Rothley, Kris

2014-04-01

Voting systems aggregate preferences efficiently and are often used for deciding conservation priorities. Desirable characteristics of voting systems include transitivity, completeness, and Pareto optimality, among others. Voting systems that are common and potentially useful for environmental decision making include simple majority, approval, and preferential voting. Unfortunately, no voting system can guarantee an outcome, while also satisfying a range of very reasonable performance criteria. Furthermore, voting methods may be manipulated by decision makers and strategic voters if they have knowledge of the voting patterns and alliances of others in the voting populations. The difficult properties of voting systems arise in routine decision making when there are multiple criteria and management alternatives. Because each method has flaws, we do not endorse one method. Instead, we urge organizers to be transparent about the properties of proposed voting systems and to offer participants the opportunity to approve the voting system as part of the ground rules for operation of a group. © 2014 The Authors. Conservation Biology published by Wiley Periodicals, Inc., on behalf of the Society for Conservation Biology.

Using Multimodal Input for Autonomous Decision Making for Unmanned Systems

NASA Technical Reports Server (NTRS)

Neilan, James H.; Cross, Charles; Rothhaar, Paul; Tran, Loc; Motter, Mark; Qualls, Garry; Trujillo, Anna; Allen, B. Danette

2016-01-01

Autonomous decision making in the presence of uncertainly is a deeply studied problem space particularly in the area of autonomous systems operations for land, air, sea, and space vehicles. Various techniques ranging from single algorithm solutions to complex ensemble classifier systems have been utilized in a research context in solving mission critical flight decisions. Realized systems on actual autonomous hardware, however, is a difficult systems integration problem, constituting a majority of applied robotics development timelines. The ability to reliably and repeatedly classify objects during a vehicles mission execution is vital for the vehicle to mitigate both static and dynamic environmental concerns such that the mission may be completed successfully and have the vehicle operate and return safely. In this paper, the Autonomy Incubator proposes and discusses an ensemble learning and recognition system planned for our autonomous framework, AEON, in selected domains, which fuse decision criteria, using prior experience on both the individual classifier layer and the ensemble layer to mitigate environmental uncertainty during operation.

Food choice decision-making by women with gestational diabetes.

PubMed

Hui, Amy Leung; Sevenhuysen, Gustaaf; Harvey, Dexter; Salamon, Elizabeth

2014-02-01

To enhance the dietary education presented to women with gestational diabetes (GDM) by exploring the reasons and experiences that women with GDM reported in making their food-choice decisions after receipt of dietary education from a healthcare professional. Food Choice Map (FCM) semi-structured in-depth interviews were conducted with 30 women with GDM living in the Winnipeg area during their pregnancies. Verbatim transcripts were generated from the interviews. A constant comparative method was used to generate common themes to answer research inquiries. Personal food preferences, hunger and cravings were the main factors affecting food choice decision-making in women with GDM. Although the information from healthcare professionals was 1 factor that affected food choice decision-making for most of the participants, more than half of the women, including all the women who were on insulin, reported difficulties in quick adaptation to dietary management in a limited time period. Information from other sources such as family members, friends, and internet were used to cope with the adaptation. These difficulties led to a sense of decreased control of GDM and were accompanied by frustration, especially for women taking insulin. Food choice decision-making varied for this group of women with GDM. Knowledge and information aided in making healthy food choices and in portion control. However, balancing individual needs and blood glucose control in a short time period was felt to be difficult and created frustration. The findings suggested that dietary consultation needs to be personalized and to be time sensitive to promote confidence in self-control. Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

How people with dementia and their families decide about moving to a care home and support their needs: development of a decision aid, a qualitative study.

PubMed

Lord, Kathryn; Livingston, Gill; Robertson, Sarah; Cooper, Claudia

2016-03-21

People with dementia and their relatives find decisions about the person with dementia living in a care home difficult. We interviewed 20 people with dementia or family carers around the time of this decision in order to design a decision-aid. Decision-makers balanced the competing priorities of remaining somewhere familiar, family's wish they remain at home, reduction of risk and effects on carer's and person with dementia's physical health. The person with dementia frequently resented their lack of autonomy as decisions about care home moves were made after insight and judgment were impaired. Family consultation usually helped carers but sometimes exacerbated tensions. Direct professional support was appreciated where it was available. There is a need for healthcare professionals to facilitate these conversations around decision-making and to include more than signposting to other organisations. There is a need for a healthcare professional facilitated decision-aid. This should detail what might change for the person with dementia and their carer, possible resources and alternatives and assist in facilitating discussion with the wider family; further research will develop and test a tool to facilitate decision making about place of care needs.

Pediatric oncologists' attitudes towards involving adolescents in decision-making concerning research participation.

PubMed

de Vries, Martine C; Wit, Jan M; Engberts, Dirk P; Kaspers, Gertjan J L; van Leeuwen, Evert

2010-07-15

Various regulations and guidelines stipulate the importance of involving adolescents in decision-making concerning research participation. Several studies have shown that in the context of pediatric oncology this involvement is difficult to achieve due to emotional stress, the complexity of research protocols and limited time. Still, up to 80% of adolescents with cancer enter onto a trial during their illness. The aim of this study was to determine clinicians' views and attitudes towards enrolling adolescents in research, considering the difficulties surrounding their involvement in decision-making. A qualitative multicenter study was performed, using in-depth semi-structured interviews on the informed consent process with 15 pediatric hemato-oncologists. Four central themes emerged that characterize clinicians' attitudes towards involving adolescents in the decision-making process: (1) clinicians regard most adolescents as not capable of participating meaningfully in discussions regarding research; (2) clinicians do not always provide adolescents with all information; (3) proxy consent from parents is obtained and is deemed sufficient; (4) clinician-investigator integrity: clinicians judge research protocols as not being harmful and even in the best interest of the adolescent. Clinicians justify not involving adolescents in research discussions by referring to best interest arguments (adolescents' incompetence, proxy consent, and investigator integrity), although this is not in line with legal regulations and ethical guidelines.

Mock Pages Are a Valid Construct for Assessment of Clinical Decision Making and Interprofessional Communication.

PubMed

Boehler, Margaret L; Schwind, Cathy J; Markwell, Stephen J; Minter, Rebecca M

2017-01-01

Answering pages from nurses about patients in need of immediate attention is one of the most difficult challenges a resident faces during their first days as a physician. A Mock Page program has been developed and adopted into a national surgical resident preparatory curriculum to prepare senior medical students for this important skill. The purpose of this study is to assess standardized mock page cases as a valid construct to assess clinical decision making and interprofessional communication skills. Mock page cases (n = 16) were administered to 213 senior medical students from 12 medical schools participating in a national surgical resident preparatory curriculum in 2013 and 2014. Clinical decision making and interprofessional communication were measured by case-specific assessments evaluating these skills which have undergone rigorous standard-setting to determine pass/fail cut points. Students' performance improved in general for both communication and clinical decision making over the 4-week course. Cases have been identified that seem to be best suited for differentiating high- from low-performing students. Chest pain, pulmonary embolus, and mental status change cases posed the greatest difficulty for student learners. Simulated mock pages demonstrate an innovative technique for training students in both effective interprofessional communication and management of common postoperative conditions they will encounter as new surgical interns.

The activity in the anterior insulae is modulated by perceptual decision-making difficulty.

PubMed

Lamichhane, Bidhan; Adhikari, Bhim M; Dhamala, Mukesh

2016-07-07

Previous neuroimaging studies provide evidence for the involvement of the anterior insulae (INSs) in perceptual decision-making processes. However, how the insular cortex is involved in integration of degraded sensory information to create a conscious percept of environment and to drive our behaviors still remains a mystery. In this study, using functional magnetic resonance imaging (fMRI) and four different perceptual categorization tasks in visual and audio-visual domains, we measured blood oxygen level dependent (BOLD) signals and examined the roles of INSs in easy and difficult perceptual decision-making. We created a varying degree of degraded stimuli by manipulating the task-specific stimuli in these four experiments to examine the effects of task difficulty on insular cortex response. We hypothesized that significantly higher BOLD response would be associated with the ambiguity of the sensory information and decision-making difficulty. In all of our experimental tasks, we found the INS activity consistently increased with task difficulty and participants' behavioral performance changed with the ambiguity of the presented sensory information. These findings support the hypothesis that the anterior insulae are involved in sensory-guided, goal-directed behaviors and their activities can predict perceptual load and task difficulty. Copyright © 2016 IBRO. Published by Elsevier Ltd. All rights reserved.

Modelling the impacts of new diagnostic tools for tuberculosis in developing countries to enhance policy decisions.

PubMed

Langley, Ivor; Doulla, Basra; Lin, Hsien-Ho; Millington, Kerry; Squire, Bertie

2012-09-01

The introduction and scale-up of new tools for the diagnosis of Tuberculosis (TB) in developing countries has the potential to make a huge difference to the lives of millions of people living in poverty. To achieve this, policy makers need the information to make the right decisions about which new tools to implement and where in the diagnostic algorithm to apply them most effectively. These decisions are difficult as the new tools are often expensive to implement and use, and the health system and patient impacts uncertain, particularly in developing countries where there is a high burden of TB. The authors demonstrate that a discrete event simulation model could play a significant part in improving and informing these decisions. The feasibility of linking the discrete event simulation to a dynamic epidemiology model is also explored in order to take account of longer term impacts on the incidence of TB. Results from two diagnostic districts in Tanzania are used to illustrate how the approach could be used to improve decisions.

Non-completion and informed consent.

PubMed

Wertheimer, Alan

2014-02-01

There is a good deal of biomedical research that does not produce scientifically useful data because it fails to recruit a sufficient number of subjects. This fact is typically not disclosed to prospective subjects. In general, the guidance about consent concerns the information required to make intelligent self-interested decisions and ignores some of the information required for intelligent altruistic decisions. Bioethics has worried about the 'therapeutic misconception', but has ignored the 'completion misconception'. This article argues that, other things being equal, prospective subjects should be informed about the possibility of non-completion as part of the standard consent process if (1) it is or should be anticipatable that there is a non-trivial possibility of non-completion and (2) that information is likely to be relevant to a prospective subject's decision to consent. The article then considers several objections to the argument, including the objection that disclosing non-completion information would make recruitment even more difficult.

Bourdieu at the bedside: briefing parents in a pediatric hospital.

PubMed

LeGrow, Karen; Hodnett, Ellen; Stremler, Robyn; McKeever, Patricia; Cohen, Eyal

2014-12-01

The philosophy of family-centered care (FCC) promotes partnerships between families and staff to plan, deliver, and evaluate services for children and has been officially adopted by a majority of pediatric hospitals throughout North America. However, studies indicated that many parents have continued to be dissatisfied with their decision-making roles in their child's care. This is particularly salient for parents of children with chronic ongoing complex health problems. These children are dependent upon medical technology and require frequent hospitalizations during which parents must contribute to difficult decisions regarding their child's care. Given this clinical issue, an alternative theoretical perspective was explored to redress this problem. Pierre Bourdieu's theoretical concepts of field, capital, and habitus were used to analyze the hierarchical relationships in pediatric acute care hospitals and to design a briefing intervention aimed at improving parents' satisfaction with decision making in that health care setting. © 2014 John Wiley & Sons Ltd.

Are You Morally Modified?

PubMed Central

Levy, Neil; Douglas, Thomas; Kahane, Guy; Terbeck, Sylvia; Cowen, Philip J.; Hewstone, Miles; Savulescu, Julian

2015-01-01

A number of concerns have been raised about the possible future use of pharmaceuticals designed to enhance cognitive, affective, and motivational processes, particularly where the aim is to produce morally better decisions or behavior. In this article, we draw attention to what is arguably a more worrying possibility: that pharmaceuticals currently in widespread therapeutic use are already having unintended effects on these processes, and thus on moral decision making and morally significant behavior. We review current evidence on the moral effects of three widely used drugs or drug types: (i) propranolol, (ii) selective serotonin reuptake inhibitors, and (iii) drugs that effect oxytocin physiology. This evidence suggests that the alterations to moral decision making and behavior caused by these agents may have important and difficult-to-evaluate consequences, at least at the population level. We argue that the moral effects of these and other widely used pharmaceuticals warrant further empirical research and ethical analysis. PMID:25892904

Difficult Decisions: A Qualitative Exploration of the Statistical Decision Making Process from the Perspectives of Psychology Students and Academics

PubMed Central

Allen, Peter J.; Dorozenko, Kate P.; Roberts, Lynne D.

2016-01-01

Quantitative research methods are essential to the development of professional competence in psychology. They are also an area of weakness for many students. In particular, students are known to struggle with the skill of selecting quantitative analytical strategies appropriate for common research questions, hypotheses and data types. To begin understanding this apparent deficit, we presented nine psychology undergraduates (who had all completed at least one quantitative methods course) with brief research vignettes, and asked them to explicate the process they would follow to identify an appropriate statistical technique for each. Thematic analysis revealed that all participants found this task challenging, and even those who had completed several research methods courses struggled to articulate how they would approach the vignettes on more than a very superficial and intuitive level. While some students recognized that there is a systematic decision making process that can be followed, none could describe it clearly or completely. We then presented the same vignettes to 10 psychology academics with particular expertise in conducting research and/or research methods instruction. Predictably, these “experts” were able to describe a far more systematic, comprehensive, flexible, and nuanced approach to statistical decision making, which begins early in the research process, and pays consideration to multiple contextual factors. They were sensitive to the challenges that students experience when making statistical decisions, which they attributed partially to how research methods and statistics are commonly taught. This sensitivity was reflected in their pedagogic practices. When asked to consider the format and features of an aid that could facilitate the statistical decision making process, both groups expressed a preference for an accessible, comprehensive and reputable resource that follows a basic decision tree logic. For the academics in particular, this aid should function as a teaching tool, which engages the user with each choice-point in the decision making process, rather than simply providing an “answer.” Based on these findings, we offer suggestions for tools and strategies that could be deployed in the research methods classroom to facilitate and strengthen students' statistical decision making abilities. PMID:26909064

Difficult Decisions: A Qualitative Exploration of the Statistical Decision Making Process from the Perspectives of Psychology Students and Academics.

PubMed

Allen, Peter J; Dorozenko, Kate P; Roberts, Lynne D

2016-01-01

Quantitative research methods are essential to the development of professional competence in psychology. They are also an area of weakness for many students. In particular, students are known to struggle with the skill of selecting quantitative analytical strategies appropriate for common research questions, hypotheses and data types. To begin understanding this apparent deficit, we presented nine psychology undergraduates (who had all completed at least one quantitative methods course) with brief research vignettes, and asked them to explicate the process they would follow to identify an appropriate statistical technique for each. Thematic analysis revealed that all participants found this task challenging, and even those who had completed several research methods courses struggled to articulate how they would approach the vignettes on more than a very superficial and intuitive level. While some students recognized that there is a systematic decision making process that can be followed, none could describe it clearly or completely. We then presented the same vignettes to 10 psychology academics with particular expertise in conducting research and/or research methods instruction. Predictably, these "experts" were able to describe a far more systematic, comprehensive, flexible, and nuanced approach to statistical decision making, which begins early in the research process, and pays consideration to multiple contextual factors. They were sensitive to the challenges that students experience when making statistical decisions, which they attributed partially to how research methods and statistics are commonly taught. This sensitivity was reflected in their pedagogic practices. When asked to consider the format and features of an aid that could facilitate the statistical decision making process, both groups expressed a preference for an accessible, comprehensive and reputable resource that follows a basic decision tree logic. For the academics in particular, this aid should function as a teaching tool, which engages the user with each choice-point in the decision making process, rather than simply providing an "answer." Based on these findings, we offer suggestions for tools and strategies that could be deployed in the research methods classroom to facilitate and strengthen students' statistical decision making abilities.

Feelings Associated with Being a Carrier and Characteristics of Reproductive Decision Making in Women Known to Be Carriers of X-linked Conditions.

PubMed

Kay, Elizabeth; Kingston, Helen

2002-03-01

Qualitative data were collected from 14 women known to be carriers of an X-linked condition associated with 'serious' disability on feelings about being a carrier and impact on reproductive decisions. Guilt and responsibility were commonly expressed by carriers about issues surrounding pregnancy. Personal experience of the condition influenced their approach to reproductive decisions. Those who had lived with an affected brother were more concrete in their decisions to avoid having an affected child compared to those with less personal experience of the condition. It is concluded that feelings of guilt associated with difficult reproductive decisions are reflected in the strong sense of responsibility attached to being a carrier. Personal experience of the condition has a clear influence on reproductive decisions of X-linked carriers.

A management-oriented framework for selecting metrics used to assess habitat- and path-specific quality in spatially structured populations

USGS Publications Warehouse

Nicol, Sam; Wiederholt, Ruscena; Diffendorfer, James E.; Mattsson, Brady; Thogmartin, Wayne E.; Semmens, Darius J.; Laura Lopez-Hoffman,; Norris, Ryan

2016-01-01

Mobile species with complex spatial dynamics can be difficult to manage because their population distributions vary across space and time, and because the consequences of managing particular habitats are uncertain when evaluated at the level of the entire population. Metrics to assess the importance of habitats and pathways connecting habitats in a network are necessary to guide a variety of management decisions. Given the many metrics developed for spatially structured models, it can be challenging to select the most appropriate one for a particular decision. To guide the management of spatially structured populations, we define three classes of metrics describing habitat and pathway quality based on their data requirements (graph-based, occupancy-based, and demographic-based metrics) and synopsize the ecological literature relating to these classes. Applying the first steps of a formal decision-making approach (problem framing, objectives, and management actions), we assess the utility of metrics for particular types of management decisions. Our framework can help managers with problem framing, choosing metrics of habitat and pathway quality, and to elucidate the data needs for a particular metric. Our goal is to help managers to narrow the range of suitable metrics for a management project, and aid in decision-making to make the best use of limited resources.

[How much business management does a surgeon need?].

PubMed

Bork, U; Koch, M; Büchler, M W; Weitz, J

2010-08-01

The present day healthcare system in Germany is rapidly changing, even more so after the introduction of diagnosis-related groups. The basic requirements for every surgeon remain manual skills, a profound clinical knowledge and the ability for clinical decision-making even in difficult situations. However, these key elements of surgical education no longer fulfill the requirements for today's leaders in surgery. New requirements, consisting of administrative duties, strategic decision-making and department management are too complex to be made only intuitively. Nowadays surgeons also need a profound education in management skills and knowledge of economic mechanisms in order to run an efficient, profitable, patient-oriented surgical department. Every surgeon who aims at obtaining a leadership position should acquire the necessary knowledge and skills.

Commentary: Transdiagnostic neuroscience of child and adolescent mental disorders--differentiating decision-making in attention-deficit/hyperactivity disorder, conduct disorder, depression and anxiety. A commentary on Sonuga-Barke et al. (2016).

PubMed

Rohde, Luis Augusto

2016-03-01

Sonuga-Barke, Cortese, Fairchild, and Stringaris offer us new insights not only on the neuropsychological processes and neurobiological mechanisms involved in the decision-making process but also how some of the most relevant child mental disorders might impact this process through a very comprehensive review of the pertinent literature. Although it is difficult to select specific points for discussing in a so dense review, I would like to highlight some aspects for 'whetting readers appetite' and seduce them to be in contact with the fascinating neurobiology behind an essential aspect of our lives. © 2016 Association for Child and Adolescent Mental Health.

Compassionate use of experimental therapies: who should decide?

PubMed Central

Zettler, Patricia J

2015-01-01

In addition to being an example of unsubstantiated hype about regenerative medicine, the controversy around the Italy-based Stamina Foundation's unproven stem cell therapy represents another chapter in a continuing debate about how to balance patients' requests for early access to experimental medicines with requirements for demonstrating safety and effectiveness. Compassionate use of the Stamina therapy arguably should not have been permitted under Italy's laws, but public pressure was intense and judges ultimately granted access. One lesson from these events is that expert regulatory agencies may be the institutions most competent to make compassionate use decisions and that policies should include more specific criteria for authorizing compassionate use. But even where regulatory agencies make decisions based on clear rules, difficult questions will arise. PMID:26202382

Sexuality and physical intimacy in long-term care.

PubMed

Lichtenberg, Peter A

2014-01-01

Sexuality and sexual needs in older adults remains a neglected area of clinical intervention, particularly so in long-term care settings. Because older adults in medical rehabilitation and long-term care beds present with significant frailties, and often significant neurocognitive disorders, it makes it difficult for occupational therapists and other staff to evaluate the capacity of an older adult resident to participate in sexual relationships. The current paper reviews the current literature on sexuality and aging, examines some of the clinical practices and guidelines regarding sexual expression in long-term care, and presents two case examples. A semistructured interview and decision tree is presented to assist therapists in making careful and informed decisions and thereby balancing the needs for protection with the needs for autonomy.

Selecting and starting an orthopaedic surgery practice.

PubMed

Mishra, Allan; Urquhart, Andrew G; Anders, Geoffrey T

2008-01-01

Every new surgeon is faced with the same question as their residency or fellowship draws to a close: What is next? Few residents or fellows are as well prepared to answer that question as they could be. Most programs do not teach residents how to choose a practice type and location. After formal orthopaedic training, new surgeons must make decisions about their careers that can be nearly as complex and difficult as the decisions they make in the operating room. Career choices have both significant and long-term effects on the physician's financial situation, career satisfaction, and personal life. The physician should be aware of key non academic issues that arise when completing a residency program or just beginning the practice of orthopaedic surgery.

A novel medical information management and decision model for uncertain demand optimization.

PubMed

Bi, Ya

2015-01-01

Accurately planning the procurement volume is an effective measure for controlling the medicine inventory cost. Due to uncertain demand it is difficult to make accurate decision on procurement volume. As to the biomedicine sensitive to time and season demand, the uncertain demand fitted by the fuzzy mathematics method is obviously better than general random distribution functions. To establish a novel medical information management and decision model for uncertain demand optimization. A novel optimal management and decision model under uncertain demand has been presented based on fuzzy mathematics and a new comprehensive improved particle swarm algorithm. The optimal management and decision model can effectively reduce the medicine inventory cost. The proposed improved particle swarm optimization is a simple and effective algorithm to improve the Fuzzy interference and hence effectively reduce the calculation complexity of the optimal management and decision model. Therefore the new model can be used for accurate decision on procurement volume under uncertain demand.

Tailoring and evaluating an intervention to improve shared decision-making among seniors with dementia, their caregivers, and healthcare providers: study protocol for a randomized controlled trial.

PubMed

Giguere, Anik M C; Lawani, Moulikatou Adouni; Fortier-Brochu, Émilie; Carmichael, Pierre-Hugues; Légaré, France; Kröger, Edeltraut; Witteman, Holly O; Voyer, Philippe; Caron, Danielle; Rodríguez, Charo

2018-06-25

The increasing prevalence of Alzheimer's disease and other forms of dementia raises new challenges to ensure that healthcare decisions are informed by research evidence and reflect what is important for seniors and their caregivers. Therefore, we aim to evaluate a tailored intervention to help healthcare providers empower seniors and their caregivers in making health-related decisions. In two phases, we will: (1) design and tailor the intervention; and (2) implement and evaluate it. We will use theory and user-centered design to tailor an intervention comprising a distance professional training program on shared decision-making and five shared decision-making tools dealing with difficult decisions often faced by seniors with dementia and their caregivers. Each tool will be designed in two versions, one for clinicians and one for patients. We will recruit 49 clinicians and 27 senior/caregiver to participate in three cycles of design-evaluation-feedback of each intervention components. Besides think-aloud and interview approaches, users will also complete questionnaires based on the Theory of Planned Behavior to identify the factors most likely to influence their adoption of shared decision-making after exposure to the intervention. We will then modify the intervention by adding/enhancing behavior-change techniques targeting these factors. We will evaluate the effectiveness of this tailored intervention before/after implementation, in a two-armed, clustered randomized trial. We will enroll a convenience sample of six primary care clinics (unit of randomization) in the province of Quebec and recruit the clinicians who practice there (mostly family physicians, nurses, and social workers). These clinics will then be randomized to immediate exposure to the intervention or delayed exposure. Overall, we will recruit 180 seniors with dementia, their caregivers, and their healthcare providers. We will evaluate the impact of the intervention on patient involvement in the decision-making process, decisional comfort, patient and caregiver personal empowerment in relation to their own healthcare, patient quality of life, caregiver burden, and decisional regret. The intervention will empower patients and their caregivers in their healthcare, by fostering their participation as partners during the decision-making process and by ensuring they make informed decisions congruent with their values and priorities. ClinicalTrials.org, NCT02956694 . Registered on 31 October 2016.

Lack of support structures in prioritization decision making concerning patients and resources. Interviews with Swedish physicians.

PubMed

Werntoft, Elisabet; Edberg, Anna-Karin

2011-08-01

To investigate physicians' experiences in relation to prioritization and financing in health care in order to gain a deeper understanding of the reasons behind their standpoints. Eighteen physicians, seven women and eleven men, aged 30 to 69 years were interviewed and the text was analyzed using an inductive approach, also described as conventional qualitative content analysis. Experience of setting healthcare priorities and difficult decision making differed widely among the physicians and seemed to be related to the number of years in professional practice. Their view of how resources should be allocated between disciplines/patients showed that they wanted politicians to make the decisions, with support from medical professions. The overwhelming impression of their reasoning showed that they lacked support structures for their decision making and could be understood under the following categories: prioritisation, easier in theory than in practice, and increasing costs threaten the Swedish welfare model. The findings of this study highlight the importance of practical national guidelines concerning vertical prioritization, also as an important measure to make prioritization more distinct and transparent. The physicians further had a need for tools to increase patients' awareness of their health. The findings of this study also showed that an awareness of the actual costs involved might increase the responsibility among both physicians and patients. The physicians' lack of support structures implies an urgent need for practical national guidelines, especially concerning vertical prioritization. This will also make prioritization appear clear and transparent for citizens.

Accepting or declining dialysis: considerations taken into account by elderly patients with end-stage renal disease.

PubMed

Visser, Annemieke; Dijkstra, Geke J; Kuiper, Daphne; de Jong, Paul E; Franssen, Casper F M; Gansevoort, Ron T; Izaks, Gerbrand J; Jager, Kitty J; Reijneveld, Sijmen A

2009-01-01

Elderly patients with end-stage renal disease have to make a difficult decision whether or not to start dialysis. This study explores the considerations taken into account by these patients in decision-making regarding renal replacement therapy. In-depth interviews were conducted to gain an enhanced understanding of the considerations in treatment decision-making. Fourteen patients aged 65 years or older participated in the interviews, of whom 8 patients had made the decision to start, and 6 patients the decision to decline, dialysis. All participating patients had a variety of health problems, but appeared to have normal cognitive functions. Patients who declined dialysis were older and more often men and widow(er)s compared with patients who accepted dialysis. Patients chose to start dialysis because they enjoyed life, were not prepared to face the end of life, felt they had no other choice or had care-giving responsibilities for family members. Patients declined dialysis because of the speculated loss of autonomy, their age-associated decrease in vitality, distance from dialysis center and reluctance to think about the future. Results suggest that patients' decisions to decline or accept dialysis are not based on the effectiveness of the treatment, but rather on personal values, beliefs and feelings toward life, suffering and death, and the expected difficulties in fitting the treatment into their life.

Bridging the gap between evidence and policy for infectious diseases: How models can aid public health decision-making.

PubMed

Knight, Gwenan M; Dharan, Nila J; Fox, Gregory J; Stennis, Natalie; Zwerling, Alice; Khurana, Renuka; Dowdy, David W

2016-01-01

The dominant approach to decision-making in public health policy for infectious diseases relies heavily on expert opinion, which often applies empirical evidence to policy questions in a manner that is neither systematic nor transparent. Although systematic reviews are frequently commissioned to inform specific components of policy (such as efficacy), the same process is rarely applied to the full decision-making process. Mathematical models provide a mechanism through which empirical evidence can be methodically and transparently integrated to address such questions. However, such models are often considered difficult to interpret. In addition, models provide estimates that need to be iteratively re-evaluated as new data or considerations arise. Using the case study of a novel diagnostic for tuberculosis, a framework for improved collaboration between public health decision-makers and mathematical modellers that could lead to more transparent and evidence-driven policy decisions for infectious diseases in the future is proposed. The framework proposes that policymakers should establish long-term collaborations with modellers to address key questions, and that modellers should strive to provide clear explanations of the uncertainty of model structure and outputs. Doing so will improve the applicability of models and clarify their limitations when used to inform real-world public health policy decisions. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

Competency and common law: why and how decision-making capacity criteria should be drawn from the capacity-determination process.

PubMed

Baron, C H

2000-06-01

Determining competence to request physician-assisted suicide should be no more difficult than determining competence to refuse life-prolonging treatment. In both cases, criteria and procedures should be developed out of the process of actually making capacity determinations; they should not be promulgated a priori. Because patient demeanor plays a critical role in capacity determinations, it should be made part of the record of such determinations through greater use of video- and audiotapes.

Contaminated salmon and the public's trust

USGS Publications Warehouse

Luoma, Samuel N.; Löfstedt, Ragnar E.

2007-01-01

Scientific uncertainties often make it difficult for environmental policy makers to determine how to communicate risks to the public. A constructive, holistic, multisectoral dialogue about an issue can improve understanding of uncertainties from different perspectives and clarify options for risk communication. Many environmental issues could benefit from explicit promotion of such a dialogue. When issues are complex, unconstructive advocacy, narrow focus, and exclusion of selected parties from decision making can erode public trust in science and lead to cynicism about the policies of government and the private sector.

Errors in Aviation Decision Making: Bad Decisions or Bad Luck?

NASA Technical Reports Server (NTRS)

Orasanu, Judith; Martin, Lynne; Davison, Jeannie; Null, Cynthia H. (Technical Monitor)

1998-01-01

Despite efforts to design systems and procedures to support 'correct' and safe operations in aviation, errors in human judgment still occur and contribute to accidents. In this paper we examine how an NDM (naturalistic decision making) approach might help us to understand the role of decision processes in negative outcomes. Our strategy was to examine a collection of identified decision errors through the lens of an aviation decision process model and to search for common patterns. The second, and more difficult, task was to determine what might account for those patterns. The corpus we analyzed consisted of tactical decision errors identified by the NTSB (National Transportation Safety Board) from a set of accidents in which crew behavior contributed to the accident. A common pattern emerged: about three quarters of the errors represented plan-continuation errors, that is, a decision to continue with the original plan despite cues that suggested changing the course of action. Features in the context that might contribute to these errors were identified: (a) ambiguous dynamic conditions and (b) organizational and socially-induced goal conflicts. We hypothesize that 'errors' are mediated by underestimation of risk and failure to analyze the potential consequences of continuing with the initial plan. Stressors may further contribute to these effects. Suggestions for improving performance in these error-inducing contexts are discussed.

How Do Trainees Choose Their First Psychotherapy Training? The Case of Training in Psychotherapy Integration

ERIC Educational Resources Information Center

Plchová, Romana; Hytych, Roman; Rihácek, Tomáš; Roubal, Jan; Vybíral, Zbynek

2016-01-01

Future trainees go through difficult decision-making processes when starting their first psychotherapy training. The choice of training in psychotherapy integration is a specific type of this process. In this study, qualitative data were obtained from the motivational letters, in-depth semi-structured interviews and e-mail questionnaires of 26…

Justice. Law in a Free Society Series. Level VI. Teacher's Guide. Second Edition.

ERIC Educational Resources Information Center

Center for Civic Education, Calabasas, CA.

This teacher's curriculum guide is designed to help high school teachers guide students to develop a better understanding of difficult issues raised by questions of justice. It is hoped that the ideas, observations, questions, and procedures students learn in the curriculum will help them to make informed decisions about how to promote justice and…

Time on Text and Science Achievement for High School Biology Students

ERIC Educational Resources Information Center

Wyss, Vanessa L.; Dolenc, Nathan; Kong, Xiaoqing; Tai, Robert H.

2013-01-01

The conflict between the amount of material to be addressed in high school science classes, the need to prepare students for standardized tests, and the amount of time available forces science educators to make difficult pedagogical decisions on a daily basis. Hands-on and inquiry-based learning offer students more authentic learning experiences…

"My Past Is a Double Edge Sword": Temporality and Reflexivity in Mature Learners

ERIC Educational Resources Information Center

Stevenson, Jacqueline; Clegg, Sue

2013-01-01

This paper discusses the ways in which mature students orientate themselves towards the future in making decisions to access higher education (HE). Their narratives connect their past, often difficult, educational and personal lives to their future aspirations and to their current experiences in further education (FE) and HE. The research was part…

States' Accommodations Policies and Development of Alternate Assessments Based on Modified Achievement Standards: A Discriminant Analysis

ERIC Educational Resources Information Center

Lazarus, Sheryl S.; Cormier, Damien C.; Thurlow, Martha L.

2011-01-01

The characteristics of a state's accommodations policy may affect a state's decision about whether to develop an alternate assessment based on modified achievement standards (AA-MAS). A very restrictive accommodations policy may make it more difficult for some students to participate in the state's regular assessment used for accountability…

Review and recommendations for climate change vulnerability assessment approaches with examples from the Southwest

Treesearch

M. Friggens; K. Bagne; D. Finch; D. Falk; J. Triepke; A. Lynch

2013-01-01

Climate change creates new challenges for resource managers and decision-makers with broad and often complex effects that make it difficult to accurately predict and design management actions to minimize undesirable impacts. We review pertinent information regarding methods and approaches used to conduct climate change vulnerability assessments to reveal assumptions...

Reviewing Quantitative Research To Inform Educational Policy Processes. Fundamentals of Educational Planning.

ERIC Educational Resources Information Center

Hite, Seven J.

Educational planners and policymakers are rarely able to base their decision-making on sound information and research, according to this book. Because the situation is even more difficult in developing countries, educational policy often is based on research conducted in others parts of the world. This book provides a practical framework that can…

An Examination of the Relationships among Student Services Expenditures, Pell Grant Funding, and Completion Rates at Public Community Colleges

ERIC Educational Resources Information Center

Racioppi, Gerald William

2014-01-01

Because of shrinking budgets, increasing demand, and calls for more graduates, community college leaders are forced to make difficult resource allocation decisions. In many states, sizable percentages of the state funds available to community colleges are conditional on performance measures, including graduations; the number of states with funding…

Self-Assessment of Governance Teams in an Argentine Private University: Adapting to Difficult Times

ERIC Educational Resources Information Center

Durand, Julio; Pujadas, Carlos

2004-01-01

Argentine Universities like similar institutions all around the world are facing a complex and challenging environment that demands a more sophisticated leadership and the development of complex managerial skills. In this paper we propose that enhancing the quality of collective decision making, and building more complex teams as a way to preserve…

The Student Role in Faculty Selection, Evaluation And Retention.

ERIC Educational Resources Information Center

Jenks, R. Stephen; And Others

Arguing that it is difficult to discuss the student's role in faculty selection, evaluation and retention outside the broader context of the student's role in decision making (see Jenks, HE 001 251), the author describes the new unicameral system at the University of New Hampshire and some of the processes the institution went through in achieving…

Deciding in Democracies: A Role for Thinking Skills?

ERIC Educational Resources Information Center

Gardner, Peter

2014-01-01

In societies that respect our right to decide many things for ourselves, exercising that right can be a source of anxiety. We want to make the right decisions, which is difficult when we are confronted with complex issues that are usually the preserve of specialists. But is help at hand? Are thinking skills the very things that non-specialists…

We Elect a President: Using Literature to Teach Decision-Making Skills

ERIC Educational Resources Information Center

Obenchain, Kathryn M.; Pennington, Julie L.

2012-01-01

The integration of social studies and literacy is often touted as a way to bring social studies back into the literacy- and math-dominated classroom of the high-stakes testing era. Curricular integration done well is difficult; if done poorly, essential social studies content, concepts, and skills may be only superficially addressed. The authors…

A restoration practitioner's guide to the restoration gene pool concept

Treesearch

Thomas A. Jones; Thomas A. Monaco

2007-01-01

Choosing plant materials for each desired species is often one of the most difficult steps in developing a restoration plan. The Restoration Gene Pool concept was developed to clarify the options available to the ecological restoration practitioner in terms of plant materials. We present a decision-making flowchart incorporating the issues delineated in the Restoration...

Theory and Practice: The Rationale for a Career Guidance Workbook.

ERIC Educational Resources Information Center

Katz, Martin R.

Although theories of career decision making and guidance are usually offered as a basis for practice, the linkage between such theories and the practices of counselors is not always clear. Since treatment in a private dyadic context is difficult to observe and classify, public treatments such as workbooks or computerized systems are more useful…

Integrative complexity of wildfire management: development of a scale

Treesearch

Joshua Carroll; Alan Bright

2007-01-01

Wildfire in the West has become a controversial natural resource issue that has divided the public's perceptions regarding its management, and forest managers are now faced with the difficult task of making sound decisions while balancing these varying concerns. Two widely used wildfi re management practices are prescribed fire and mechanical thinning. In order to...

An Evidence-Centered Approach to Using Assessment Data for Policymakers. Research Report. ETS RR-10-03

ERIC Educational Resources Information Center

Underwood, Jody S.; Zapata-Rivera, Diego; VanWinkle, Waverely

2010-01-01

District-level policymakers are challenged to use evidence of student achievement to make policy decisions, such as professional development and other school improvement plans. They currently receive reports of student achievement data that are complex, difficult to read, and even harder to interpret. Using the research literature on policymakers'…

Food Business Entrepreneurship

NASA Astrophysics Data System (ADS)

Weber, Peter

Though not a very traditional career path for food scientists, one option is to go into business for yourself by starting a food business. Food business entrepreneurship is a difficult career that entails long work hours, extensive decision making, and tasks that require knowledge beyond food science. However, there is high potential for rewards, including financial rewards, career progression, and personal flexibility.

The Role of E-Mentoring in Helping College Sophomores Persist and Stay Enrolled

ERIC Educational Resources Information Center

Harris, Robert E.

2012-01-01

The college sophomore year is considered a difficult year for many students. College sophomores tend to experience the least amount of attention and support during a time when they are pursuing academic and personal goals. When these students encounter challenges that coincide with a limited amount of assistance with decision making, they can…

Low- and Moderate-Income Solar Policy Basics | State, Local, and Tribal

Science.gov Websites

scores, which can make attaining a loan for solar investments difficult. Even in cases where loans are translate into having less control over decisions about rooftop solar and utilities. Even in cases where LMI program) to increase local solar deployment. In other cases, CDFIs and CDEs can directly facilitate

Integrating LANDIS model and a multi-criteria decision-making approach to evaluate cumulative effects of forest management in the Missouri Ozarks, USA

Treesearch

Zong Bo Shang; Hong S. He; Weimin Xi; Stephen R. Shifley; Brian J. Palik

2012-01-01

Public forest management requires consideration of numerous objectives including protecting ecosystem health, sustaining habitats for native communities, providing sustainable forest products, and providing noncommodity ecosystem services. It is difficult to evaluate the long-term, cumulative effects and tradeoffs these and other associated management objectives. To...

Application of decision science to resilience management in Jamaica Bay

USGS Publications Warehouse

Eaton, Mitchell; Fuller, Angela K.; Johnson, Fred A.; Hare, M. P.; Stedman, Richard C.; Sanderson, E.W.; Solecki, W. D.; Waldman, J.R.; Paris, A. S.

2016-01-01

This book highlights the growing interest in management interventions designed to enhance the resilience of the Jamaica Bay socio-ecological system. Effective management, whether the focus is on managing biological processes or human behavior or (most likely) both, requires decision makers to anticipate how the managed system will respond to interventions (i.e., via predictions or projections). In systems characterized by many interacting components and high uncertainty, making probabilistic predictions is often difficult and requires careful thinking not only about system dynamics, but also about how management objectives are specified and the analytic method used to select the preferred action(s). Developing a clear statement of the problem(s) and articulation of management objectives is often best achieved by including input from managers, scientists and other stakeholders affected by the decision through a process of joint problem framing (Marcot and others 2012; Keeney and others 1990). Using a deliberate, coherent and transparent framework for deciding among management alternatives to best meet these objectives then ensures a greater likelihood for successful intervention. Decision science provides the theoretical and practical basis for developing this framework and applying decision analysis methods for making complex decisions under uncertainty and risk.

Clinical decision making in the recognition of dying: a qualitative interview study.

PubMed

Taylor, Paul; Dowding, Dawn; Johnson, Miriam

2017-01-25

Recognising dying is an essential clinical skill for general and palliative care professionals alike. Despite the high importance, both identification and good clinical care of the dying patient remains extremely difficult and often controversial in clinical practice. This study aimed to answer the question: "What factors influence medical and nursing staff when recognising dying in end-stage cancer and heart failure patients?" This study used a descriptive approach to decision-making theory. Participants were purposively sampled for profession (doctor or nurse), specialty (cardiology or oncology) and grade (senior vs junior). Recruitment continued until data saturation was reached. Semi-structured interviews were conducted with NHS medical and nursing staff in an NHS Trust which contained cancer and cardiology tertiary referral centres. An interview schedule was designed, based on decision-making literature. Interviews were audio-recorded and transcribed and analysed using thematic framework. Data were managed with Atlas.ti. Saturation was achieved with 19 participants (7 seniors; 8 intermediate level staff; 4 juniors). There were 11 oncologists (6 doctors, 5 nurses) and 8 cardiologists (3 doctors, 5 nurses). Six themes were generated: information used; decision processes; modifying factors; implementation; reflecting on decisions and related decisions. The decision process described was time-dependent, ongoing and iterative, and relies heavily on intuition. This study supports the need to recognise the strengths and weaknesses of expertise and intuition as part of the decision process, and of placing the recognition of dying in a time-dependent context. Clinicians should also be prepared to accept and convey the uncertainty surrounding these decisions, both in practice and in communication with patients and carers.

Feasibility of neuro-morphic computing to emulate error-conflict based decision making.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Branch, Darren W.

2009-09-01

A key aspect of decision making is determining when errors or conflicts exist in information and knowing whether to continue or terminate an action. Understanding the error-conflict processing is crucial in order to emulate higher brain functions in hardware and software systems. Specific brain regions, most notably the anterior cingulate cortex (ACC) are known to respond to the presence of conflicts in information by assigning a value to an action. Essentially, this conflict signal triggers strategic adjustments in cognitive control, which serve to prevent further conflict. The most probable mechanism is the ACC reports and discriminates different types of feedback,more » both positive and negative, that relate to different adaptations. Unique cells called spindle neurons that are primarily found in the ACC (layer Vb) are known to be responsible for cognitive dissonance (disambiguation between alternatives). Thus, the ACC through a specific set of cells likely plays a central role in the ability of humans to make difficult decisions and solve challenging problems in the midst of conflicting information. In addition to dealing with cognitive dissonance, decision making in high consequence scenarios also relies on the integration of multiple sets of information (sensory, reward, emotion, etc.). Thus, a second area of interest for this proposal lies in the corticostriatal networks that serve as an integration region for multiple cognitive inputs. In order to engineer neurological decision making processes in silicon devices, we will determine the key cells, inputs, and outputs of conflict/error detection in the ACC region. The second goal is understand in vitro models of corticostriatal networks and the impact of physical deficits on decision making, specifically in stressful scenarios with conflicting streams of data from multiple inputs. We will elucidate the mechanisms of cognitive data integration in order to implement a future corticostriatal-like network in silicon devices for improved decision processing.« less

The development of a disease oriented eFolder for multiple sclerosis decision support

NASA Astrophysics Data System (ADS)

Ma, Kevin; Jacobs, Colin; Fernandez, James; Amezcua, Lilyana; Liu, Brent

2010-03-01

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system. The chronic nature of MS necessitates multiple MRI studies to track disease progression. Currently, MRI assessment of multiple sclerosis requires manual lesion measurement and yields an estimate of lesion volume and change that is highly variable and user-dependent. In the setting of a longitudinal study, disease trends and changes become difficult to extrapolate from the lesions. In addition, it is difficult to establish a correlation between these imaged lesions and clinical factors such as treatment course. To address these clinical needs, an MS specific e-Folder for decision support in the evaluation and assessment of MS has been developed. An e-Folder is a disease-centric electronic medical record in contrast to a patient-centric electronic health record. Along with an MS lesion computer aided detection (CAD) package for lesion load, location, and volume, clinical parameters such as patient demographics, disease history, clinical course, and treatment history are incorporated to make the e-Folder comprehensive. With the integration of MRI studies together with related clinical data and informatics tools designed for monitoring multiple sclerosis, it provides a platform to improve the detection of treatment response in patients with MS. The design and deployment of MS e-Folder aims to standardize MS lesion data and disease progression to aid in decision making and MS-related research.

Using an ecological ethics framework to make decisions about the relocation of wildlife

USGS Publications Warehouse

McCoy, E.D.; Berry, K.

2008-01-01

Relocation is an increasingly prominent conservation tool for a variety of wildlife, but the technique also is controversial, even among conservation practitioners. An organized framework for addressing the moral dilemmas often accompanying conservation actions such as relocation has been lacking. Ecological ethics may provide such a framework and appears to be an important step forward in aiding ecological researchers and biodiversity managers to make difficult moral choices. A specific application of this framework can make the reasoning process more transparent and give more emphasis to the strong sentiments about non-human organisms held by many potential users. Providing an example of the application of the framework may also increase the appeal of the reasoning process to ecological researchers and biodiversity managers. Relocation as a conservation action can be accompanied by a variety of moral dilemmas that reflect the interconnection of values, ethical positions, and conservation decisions. A model that is designed to address moral dilemmas arising from relocation of humans provides/demonstrates/illustrates a possible way to apply the ecological ethics framework and to involve practicing conservationists in the overall decision-making process. ?? 2008 Springer Science+Business Media B.V.

Parental decision-making in uptake of the MMR vaccination: a systematic review of qualitative literature.

PubMed

Allan, N; Harden, J

2015-12-01

Controversy has surrounded MMR vaccination in the aftermath of Wakefield's 1998 paper suggesting links between MMR and the development of pervasive developmental disorder in children. The paper sparked off media debate and contributed to a lack of parental trust in health-care providers and reduction in MMR uptake. This review aims to identify and evaluate research on the subject, with a view to present the reasons behind, and influences on parental decision-making in relation to MMR. Systematic search strategy identified 14 relevant papers on which thematic analysis was performed. Themes identified were categorized as follows: perceptions of risk; roles and responsibility; experience and knowledge. There were limited changes in parental decision-making factors over the time period despite an increase in uptake. Many studies fail to differentiate between accepters and rejecters, making it difficult to draw out clear conclusions. Policymakers need to adapt information provided to address these concerns. Future research should focus more on distinguishing between accepters and rejecters to determine which factors can alter outcome. © The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

The Interactive Minority Game: a Web-based investigation of human market interactions

NASA Astrophysics Data System (ADS)

Laureti, Paolo; Ruch, Peter; Wakeling, Joseph; Zhang, Yi-Cheng

2004-01-01

The unprecedented access offered by the World Wide Web brings with it the potential to gather huge amounts of data on human activities. Here we exploit this by using a toy model of financial markets, the Minority Game (MG), to investigate human speculative trading behaviour and information capacity. Hundreds of individuals have played a total of tens of thousands of game turns against computer-controlled agents in the Web-based Interactive Minority Game. The analytical understanding of the MG permits fine-tuning of the market situations encountered, allowing for investigation of human behaviour in a variety of controlled environments. In particular, our results indicate a transition in players’ decision-making, as the markets become more difficult, between deductive behaviour making use of short-term trends in the market, and highly repetitive behaviour that ignores entirely the market history, yet outperforms random decision-making.

From the Patient Perspective, Consent Forms Fall Short of Providing Information to Guide Decision Making

PubMed Central

Manta, Christine J.; Ortiz, Jacqueline; Moulton, Benjamin W.; Sonnad, Seema S.

2016-01-01

Objective This study aimed to gather qualitative feedback on patient perceptions of informed consent forms and elicit recommendations to improve readability and utility for enhanced patient safety and engagement in shared decision making. Methods Sixty in person interviews were conducted consisting of a literacy and numeracy assessment, a comprehension quiz to assess retention of key information and open ended questions to determine reactions, clarity of information and suggestions for improvement. Results While 68% of the participants had education beyond high school, many still missed comprehension questions and found the forms difficult to read. Recurrent suggestions included: specific formatting changes to enhance readability, a need for additional sources of information, mixed attitudes towards inclusion of risk information and the recognized importance of physician-patient conversations. Conclusion This study provides evidence from the patient perspective that consent forms are too complex and fail to achieve comprehension. Future studies should be conducted using patients’ suggestions for form redesign and inclusion of supplemental educational tools in order to optimize communication and safety to achieve more informed health care decision making. PMID:27490160

Money, men and markets: economic and sexual empowerment of market women in southwestern Uganda.

PubMed

Nyanzi, Barbara; Nyanzi, Stella; Wolff, Brent; Whitworth, James

2005-01-01

Market trading requires access to cash, independent decision-making, mobility and social interaction. This study sought to explore whether market work empowers women with respect to spending decisions and negotiation over sex and condom-use. A semi-structured questionnaire was administered to 212 market women; and 12 focus group discussions and 52 in-depths interviews were conducted among market women in southwestern Uganda. Market women reported high levels of independence, mobility, assertiveness and social interaction. Access to cash was not synonymous with control over it, however. Spending decisions were limited by men's ability to selectively withdraw finances for expenditures central to women's concerns including household and children's needs. Trading in markets earns women masculine labels such as kiwagi, characterized variously as independent, rebellious and insubordinate. Earning money does not change expectations of correct behaviour for wives, making it difficult for women to initiate, deny sex or ask for condoms. Independence and income from market work may make it easier for women to enter and exit new sexual relationships. However, unable to protect themselves within partnerships, HIV risk may increase as a result.

Love as a regulative ideal in surrogate decision making.

PubMed

Stonestreet, Erica Lucast

2014-10-01

This discussion aims to give a normative theoretical basis for a "best judgment" model of surrogate decision making rooted in a regulative ideal of love. Currently, there are two basic models of surrogate decision making for incompetent patients: the "substituted judgment" model and the "best interests" model. The former draws on the value of autonomy and responds with respect; the latter draws on the value of welfare and responds with beneficence. It can be difficult to determine which of these two models is more appropriate for a given patient, and both approaches may seem inadequate for a surrogate who loves the patient. The proposed "best judgment" model effectively draws on the values incorporated in each of the traditional standards, but does so because these values are important to someone who loves a patient, since love responds to the patient as the specific person she is. © The Author 2014. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Plan Execution Interchange Language (PLEXIL)

NASA Technical Reports Server (NTRS)

Estlin, Tara; Jonsson, Ari; Pasareanu, Corina; Simmons, Reid; Tso, Kam; Verma, Vandi

2006-01-01

Plan execution is a cornerstone of spacecraft operations, irrespective of whether the plans to be executed are generated on board the spacecraft or on the ground. Plan execution frameworks vary greatly, due to both different capabilities of the execution systems, and relations to associated decision-making frameworks. The latter dependency has made the reuse of execution and planning frameworks more difficult, and has all but precluded information sharing between different execution and decision-making systems. As a step in the direction of addressing some of these issues, a general plan execution language, called the Plan Execution Interchange Language (PLEXIL), is being developed. PLEXIL is capable of expressing concepts used by many high-level automated planners and hence provides an interface to multiple planners. PLEXIL includes a domain description that specifies command types, expansions, constraints, etc., as well as feedback to the higher-level decision-making capabilities. This document describes the grammar and semantics of PLEXIL. It includes a graphical depiction of this grammar and illustrative rover scenarios. It also outlines ongoing work on implementing a universal execution system, based on PLEXIL, using state-of-the-art rover functional interfaces and planners as test cases.

Towards a cyber-physical era: soft computing framework based multi-sensor array for water quality monitoring

NASA Astrophysics Data System (ADS)

Bhardwaj, Jyotirmoy; Gupta, Karunesh K.; Gupta, Rajiv

2018-02-01

New concepts and techniques are replacing traditional methods of water quality parameter measurement systems. This paper introduces a cyber-physical system (CPS) approach for water quality assessment in a distribution network. Cyber-physical systems with embedded sensors, processors and actuators can be designed to sense and interact with the water environment. The proposed CPS is comprised of sensing framework integrated with five different water quality parameter sensor nodes and soft computing framework for computational modelling. Soft computing framework utilizes the applications of Python for user interface and fuzzy sciences for decision making. Introduction of multiple sensors in a water distribution network generates a huge number of data matrices, which are sometimes highly complex, difficult to understand and convoluted for effective decision making. Therefore, the proposed system framework also intends to simplify the complexity of obtained sensor data matrices and to support decision making for water engineers through a soft computing framework. The target of this proposed research is to provide a simple and efficient method to identify and detect presence of contamination in a water distribution network using applications of CPS.

Comparative approaches to studying strategy: towards an evolutionary account of primate decision making.

PubMed

Brosnan, Sarah F; Beran, Michael J; Parrish, Audrey E; Price, Sara A; Wilson, Bart J

2013-07-18

How do primates, humans included, deal with novel problems that arise in interactions with other group members? Despite much research regarding how animals and humans solve social problems, few studies have utilized comparable procedures, outcomes, or measures across different species. Thus, it is difficult to piece together the evolution of decision making, including the roots from which human economic decision making emerged. Recently, a comparative body of decision making research has emerged, relying largely on the methodology of experimental economics in order to address these questions in a cross-species fashion. Experimental economics is an ideal method of inquiry for this approach. It is a well-developed method for distilling complex decision making involving multiple conspecifics whose decisions are contingent upon one another into a series of simple decision choices. This allows these decisions to be compared across species and contexts. In particular, our group has used this approach to investigate coordination in New World monkeys, Old World monkeys, and great apes (including humans), using identical methods. We find that in some cases there are remarkable continuities of outcome, as when some pairs in all species solved a coordination game, the Assurance game. On the other hand, we also find that these similarities in outcomes are likely driven by differences in underlying cognitive mechanisms. New World monkeys required exogenous information about their partners' choices in order to solve the task, indicating that they were using a matching strategy. Old World monkeys, on the other hand, solved the task without exogenous cues, leading to investigations into what mechanisms may be underpinning their responses (e.g., reward maximization, strategy formation, etc.). Great apes showed a strong experience effect, with cognitively enriched apes following what appears to be a strategy. Finally, humans were able to solve the task with or without exogenous cues. However, when given the chance to do so, they incorporated an additional mechanism unavailable to the other primates - language - to coordinate outcomes with their partner. We discuss how these results inform not only comparative psychology, but also evolutionary psychology, as they provide an understanding of the evolution of human economic behavior, and the evolution of decision making more broadly.

Expertise and decision-making in American football

PubMed Central

Woods, Adam J.; Kranjec, Alexander; Lehet, Matt; Chatterjee, Anjan

2015-01-01

In American football, pass interference calls can be difficult to make, especially when the timing of contact between players is ambiguous. American football history contains many examples of controversial pass interference decisions, often with fans, players, and officials interpreting the same event differently. The current study sought to evaluate the influence of experience with concepts important for officiating decisions in American football on the probability (i.e., response criteria) of pass interference calls. We further investigated the extent to which such experience modulates perceptual biases that might influence the interpretation of such events. We hypothesized that observers with less experience with the American football concepts important for pass interference would make progressively more pass interference calls than more experienced observers, even when given an explicit description of the necessary criteria for a pass interference call. In a go/no-go experiment using photographs from American football games, three groups of participants with different levels of experience with American football (Football Naïve, Football Player, and Football Official) made pass interference calls for pictures depicting left-moving and right-moving events. More experience was associated with progressively and significantly fewer pass interference calls [F(2,48) = 10.4, p < 0.001], with Football Naïve participants making the most pass interference calls, and Football Officials the least. In addition, our data replicated a prior finding of spatial biases for interpreting left-moving images more harshly than identical right-moving images, but only in Football Players. These data suggest that experience with the concepts important for making a decision may influence the rate of decision-making, and may also play a role in susceptibility to spatial biases. PMID:26217294

Expertise and decision-making in American football.

PubMed

Woods, Adam J; Kranjec, Alexander; Lehet, Matt; Chatterjee, Anjan

2015-01-01

In American football, pass interference calls can be difficult to make, especially when the timing of contact between players is ambiguous. American football history contains many examples of controversial pass interference decisions, often with fans, players, and officials interpreting the same event differently. The current study sought to evaluate the influence of experience with concepts important for officiating decisions in American football on the probability (i.e., response criteria) of pass interference calls. We further investigated the extent to which such experience modulates perceptual biases that might influence the interpretation of such events. We hypothesized that observers with less experience with the American football concepts important for pass interference would make progressively more pass interference calls than more experienced observers, even when given an explicit description of the necessary criteria for a pass interference call. In a go/no-go experiment using photographs from American football games, three groups of participants with different levels of experience with American football (Football Naïve, Football Player, and Football Official) made pass interference calls for pictures depicting left-moving and right-moving events. More experience was associated with progressively and significantly fewer pass interference calls [F (2,48) = 10.4, p < 0.001], with Football Naïve participants making the most pass interference calls, and Football Officials the least. In addition, our data replicated a prior finding of spatial biases for interpreting left-moving images more harshly than identical right-moving images, but only in Football Players. These data suggest that experience with the concepts important for making a decision may influence the rate of decision-making, and may also play a role in susceptibility to spatial biases.

Shared Mind: Communication, Decision Making, and Autonomy in Serious Illness

PubMed Central

Epstein, Ronald M.; Street, Richard L.

2011-01-01

In the context of serious illness, individuals usually rely on others to help them think and feel their way through difficult decisions. To help us to understand why, when, and how individuals involve trusted others in sharing information, deliberation, and decision making, we offer the concept of shared mind—ways in which new ideas and perspectives can emerge through the sharing of thoughts, feelings, perceptions, meanings, and intentions among 2 or more people. We consider how shared mind manifests in relationships and organizations in general, building on studies of collaborative cognition, attunement, and sensemaking. Then, we explore how shared mind might be promoted through communication, when appropriate, and the implications of shared mind for decision making and patient autonomy. Next, we consider a continuum of patient-centered approaches to patient-clinician interactions. At one end of the continuum, an interactional approach promotes knowing the patient as a person, tailoring information, constructing preferences, achieving consensus, and promoting relational autonomy. At the other end, a transactional approach focuses on knowledge about the patient, information-as-commodity, negotiation, consent, and individual autonomy. Finally, we propose that autonomy and decision making should consider not only the individual perspectives of patients, their families, and members of the health care team, but also the perspectives that emerge from the interactions among them. By drawing attention to shared mind, clinicians can observe in what ways they can promote it through bidirectional sharing of information and engaging in shared deliberation. PMID:21911765

Shared mind: communication, decision making, and autonomy in serious illness.

PubMed

Epstein, Ronald M; Street, Richard L

2011-01-01

In the context of serious illness, individuals usually rely on others to help them think and feel their way through difficult decisions. To help us to understand why, when, and how individuals involve trusted others in sharing information, deliberation, and decision making, we offer the concept of shared mind-ways in which new ideas and perspectives can emerge through the sharing of thoughts, feelings, perceptions, meanings, and intentions among 2 or more people. We consider how shared mind manifests in relationships and organizations in general, building on studies of collaborative cognition, attunement, and sensemaking. Then, we explore how shared mind might be promoted through communication, when appropriate, and the implications of shared mind for decision making and patient autonomy. Next, we consider a continuum of patient-centered approaches to patient-clinician interactions. At one end of the continuum, an interactional approach promotes knowing the patient as a person, tailoring information, constructing preferences, achieving consensus, and promoting relational autonomy. At the other end, a transactional approach focuses on knowledge about the patient, information-as-commodity, negotiation, consent, and individual autonomy. Finally, we propose that autonomy and decision making should consider not only the individual perspectives of patients, their families, and members of the health care team, but also the perspectives that emerge from the interactions among them. By drawing attention to shared mind, clinicians can observe in what ways they can promote it through bidirectional sharing of information and engaging in shared deliberation.

PROMISE AND PLAUSIBILITY: HEALTH TECHNOLOGY ADOPTION DECISIONS WITH LIMITED EVIDENCE.

PubMed

Campbell, Bruce; Knox, Paul

2016-01-01

The adoption of new medical devices and diagnostics is often hampered by lack of published evidence which makes conventional health technology assessment (HTA) difficult. We now have 5 years' experience of the Medical Technologies Advisory Committee of the National Institute for Health and Care Excellence (NICE) in the United Kingdom, addressing this problem. This committee assesses devices and diagnostics against claims of advantage, to produce guidance on adoption for the health service. We have reflected on the practical, technical, and intellectual processes we have used in developing guidance for the health service. When scientific and clinical evidence is sparse, promise and plausibility play an increased part in decision-making. Drivers of promise include a clear design and mechanism of action, the possibility of radical improvement in care and/or resource use, and improving health outcomes for large numbers of patients. Plausibility relates to judgements about the whether the promise is likely to be delivered in a "real world" setting. Promise and plausibility need to be balanced against the amount of evidence available. We examine the influence they may have on decision-making compared with other factors such as risk and cost. Decisions about adoption of new devices and diagnostics with little evidence are influenced by judgements of their promise and the plausibility of claims that they will provide benefits in a real-world setting. This kind of decision making needs to be transparent and this article explains how these influences can be balanced against the use of more familiar criteria.

Sustainability in health care by allocating resources effectively (SHARE) 3: examining how resource allocation decisions are made, implemented and evaluated in a local healthcare setting.

PubMed

Harris, Claire; Allen, Kelly; Waller, Cara; Brooke, Vanessa

2017-05-09

This is the third in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. Leaders in a large Australian health service planned to establish an organisation-wide, systematic, integrated, evidence-based approach to disinvestment. In order to introduce new systems and processes for disinvestment into existing decision-making infrastructure, we aimed to understand where, how and by whom resource allocation decisions were made, implemented and evaluated. We also sought the knowledge and experience of staff regarding previous disinvestment activities. Structured interviews, workshops and document analysis were used to collect information from multiple sources in an environmental scan of decision-making systems and processes. Findings were synthesised using a theoretical framework. Sixty-eight respondents participated in interviews and workshops. Eight components in the process of resource allocation were identified: Governance, Administration, Stakeholder engagement, Resources, Decision-making, Implementation, Evaluation and, where appropriate, Reinvestment of savings. Elements of structure and practice for each component are described and a new framework was developed to capture the relationships between them. A range of decision-makers, decision-making settings, type and scope of decisions, criteria used, and strengths, weaknesses, barriers and enablers are outlined. The term 'disinvestment' was not used in health service decision-making. Previous projects that involved removal, reduction or restriction of current practices were driven by quality and safety issues, evidence-based practice or a need to find resource savings and not by initiatives where the primary aim was to disinvest. Measuring resource savings is difficult, in some situations impossible. Savings are often only theoretical as resources released may be utilised immediately by patients waiting for beds, clinic appointments or surgery. Decision-making systems and processes for resource allocation are more complex than assumed in previous studies. There is a wide range of decision-makers, settings, scope and type of decisions, and criteria used for allocating resources within a single institution. To our knowledge, this is the first paper to report this level of detail and to introduce eight components of the resource allocation process identified within a local health service.

Application of Multi-Criteria Decision Making (MCDM) Technique for Gradation of Jute Fibres

NASA Astrophysics Data System (ADS)

Choudhuri, P. K.

2014-12-01

Multi-Criteria Decision Making is a branch of Operation Research (OR) having a comparatively short history of about 40 years. It is being popularly used in the field of engineering, banking, fixing policy matters etc. It can also be applied for taking decisions in daily life like selecting a car to purchase, selecting bride or groom and many others. Various MCDM methods namely Weighted Sum Model (WSM), Weighted Product Model (WPM), Analytic Hierarchy Process (AHP), Technique for Order Preference by Similarity to Ideal Solutions (TOPSIS) and Elimination and Choice Translating Reality (ELECTRE) are there to solve many decision making problems, each having its own limitations. However it is very difficult to decide which MCDM method is the best. MCDM methods are prospective quantitative approaches for solving decision problems involving finite number of alternatives and criteria. Very few research works in textiles have been carried out with the help of this technique particularly where decision taking among several alternatives becomes the major problem based on some criteria which are conflicting in nature. Gradation of jute fibres on the basis of the criteria like strength, root content, defects, colour, density, fineness etc. is an important task to perform. The MCDM technique provides enough scope to be applied for the gradation of jute fibres or ranking among several varieties keeping in view a particular object and on the basis of some selection criteria and their relative weightage. The present paper is an attempt to explore the scope of applying the multiplicative AHP method of multi-criteria decision making technique to determine the quality values of selected jute fibres on the basis of some above stated important criteria and ranking them accordingly. A good agreement in ranking is observed between the existing Bureau of Indian Standards (BIS) grading and proposed method.

Experiences of randomization: interviews with patients and clinicians in the SPCG-IV trial.

PubMed

Bill-Axelson, Anna; Christensson, Anna; Carlsson, Marianne; Norlén, Bo Johan; Holmberg, Lars

2008-01-01

Recruitment of both patients and clinicians to randomized trials is difficult. Low participation carries the risk of terminating studies early and making them invalid owing to insufficient statistical power. This study investigated patients' and clinicians' experiences of randomization with the aim of facilitating trial participation in the future. This was a qualitative study using content analysis. Patients offered to participate in a randomized trial and randomizing clinicians were interviewed. Five participants, four non-participants and five randomizing clinicians were interviewed, 2-8 years from randomization. Clinicians used strategies in interaction with the patients to facilitate decision making. Patients' attitudes differed and experiences of relatives or friends were often stated as reasons for treatment preferences. Patients described that letting chance decide treatment was a difficult barrier to overcome for randomization. The clinicians used a number of different strategies perceived to make randomization more acceptable to their patients. The clinicians' own motivation for randomizing patients for trials depended on the medical relevance of the study question and the clinicians' major obstacle was to maintain equipoise over time. Regular meetings with the study group helped to maintain equipoise and motivation. To establish a good platform for randomization the clinician needs to know about the patient's treatment preferences and the patient's attitude concerning the role of the clinician to facilitate decision making. The strategies used by the clinicians were perceived as helpful and could be tested in an intervention study.

Wishful Thinking? Inside the Black Box of Exposure Assessment.

PubMed

Money, Annemarie; Robinson, Christine; Agius, Raymond; de Vocht, Frank

2016-05-01

Decision-making processes used by experts when undertaking occupational exposure assessment are relatively unknown, but it is often assumed that there is a common underlying method that experts employ. However, differences in training and experience of assessors make it unlikely that one general method for expert assessment would exist. Therefore, there are concerns about formalizing, validating, and comparing expert estimates within and between studies that are difficult, if not impossible, to characterize. Heuristics on the other hand (the processes involved in decision making) have been extensively studied. Heuristics are deployed by everyone as short-cuts to make the often complex process of decision-making simpler, quicker, and less burdensome. Experts' assessments are often subject to various simplifying heuristics as a way to reach a decision in the absence of sufficient data. Therefore, investigating the underlying heuristics or decision-making processes involved may help to shed light on the 'black box' of exposure assessment. A mixed method study was conducted utilizing both a web-based exposure assessment exercise incorporating quantitative and semiqualitative elements of data collection, and qualitative semi-structured interviews with exposure assessors. Qualitative data were analyzed using thematic analysis. Twenty-five experts completed the web-based exposure assessment exercise and 8 of these 25 were randomly selected to participate in the follow-up interview. Familiar key themes relating to the exposure assessment exercise emerged; 'intensity'; 'probability'; 'agent'; 'process'; and 'duration' of exposure. However, an important aspect of the detailed follow-up interviews revealed a lack of structure and order with which participants described their decision making. Participants mostly described some form of an iterative process, heavily relying on the anchoring and adjustment heuristic, which differed between experts. In spite of having undertaken comparable training (in occupational hygiene or exposure assessment), experts use different methods to assess exposure. Decision making appears to be an iterative process with heavy reliance on the key heuristic of anchoring and adjustment. Using multiple experts to assess exposure while providing some form of anchoring scenario to build from, and additional training in understanding the impact of simple heuristics on the process of decision making, is likely to produce a more methodical approach to assessment; thereby improving consistency and transparency in expert exposure assessment. © The Author 2016. Published by Oxford University Press on behalf of the British Occupational Hygiene Society.

Wishful Thinking? Inside the Black Box of Exposure Assessment

PubMed Central

Money, Annemarie; Robinson, Christine; Agius, Raymond; de Vocht, Frank

2016-01-01

Background: Decision-making processes used by experts when undertaking occupational exposure assessment are relatively unknown, but it is often assumed that there is a common underlying method that experts employ. However, differences in training and experience of assessors make it unlikely that one general method for expert assessment would exist. Therefore, there are concerns about formalizing, validating, and comparing expert estimates within and between studies that are difficult, if not impossible, to characterize. Heuristics on the other hand (the processes involved in decision making) have been extensively studied. Heuristics are deployed by everyone as short-cuts to make the often complex process of decision-making simpler, quicker, and less burdensome. Experts’ assessments are often subject to various simplifying heuristics as a way to reach a decision in the absence of sufficient data. Therefore, investigating the underlying heuristics or decision-making processes involved may help to shed light on the ‘black box’ of exposure assessment. Methods: A mixed method study was conducted utilizing both a web-based exposure assessment exercise incorporating quantitative and semiqualitative elements of data collection, and qualitative semi-structured interviews with exposure assessors. Qualitative data were analyzed using thematic analysis. Results: Twenty-five experts completed the web-based exposure assessment exercise and 8 of these 25 were randomly selected to participate in the follow-up interview. Familiar key themes relating to the exposure assessment exercise emerged; ‘intensity’; ‘probability’; ‘agent’; ‘process’; and ‘duration’ of exposure. However, an important aspect of the detailed follow-up interviews revealed a lack of structure and order with which participants described their decision making. Participants mostly described some form of an iterative process, heavily relying on the anchoring and adjustment heuristic, which differed between experts. Conclusion: In spite of having undertaken comparable training (in occupational hygiene or exposure assessment), experts use different methods to assess exposure. Decision making appears to be an iterative process with heavy reliance on the key heuristic of anchoring and adjustment. Using multiple experts to assess exposure while providing some form of anchoring scenario to build from, and additional training in understanding the impact of simple heuristics on the process of decision making, is likely to produce a more methodical approach to assessment; thereby improving consistency and transparency in expert exposure assessment. PMID:26764244

Career Counseling as an Environmental Support: Exploring Influences on Career Choice, Career Decision-Making Self-Efficacy, and Career Barriers

ERIC Educational Resources Information Center

Makela, Julia Panke

2011-01-01

This study was motivated by concerns regarding the difficult academic and career choices facing today's college students as they navigate higher education and encounter career barriers along their paths. Using Social Cognitive Career Theory (SCCT; Lent, Brown, & Hackett, 1994) as a primary framework, the study sought to understand the role that…

The Short- to Medium-Term Predictive Accuracy of Static and Dynamic Risk Assessment Measures in a Secure Forensic Hospital

ERIC Educational Resources Information Center

Chu, Chi Meng; Thomas, Stuart D. M.; Ogloff, James R. P.; Daffern, Michael

2013-01-01

Although violence risk assessment knowledge and practice has advanced over the past few decades, it remains practically difficult to decide which measures clinicians should use to assess and make decisions about the violence potential of individuals on an ongoing basis, particularly in the short to medium term. Within this context, this study…

Informing Education Policy in Afghanistan: Using Design of Experiments and Data Envelopment Analysis to Provide Transparency in Complex Simulation

ERIC Educational Resources Information Center

Marlin, Benjamin

2013-01-01

Education planning provides the policy maker and the decision maker a logical framework in which to develop and implement education policy. At the international level, education planning is often confounded by both internal and external complexities, making the development of education policy difficult. This research presents a discrete event…

Evaluation of Natural Language Processors.

DTIC Science & Technology

1980-11-01

techniques described. Common practice in describing natural language processors is to describe the programs, then give about 20 examples of correctly...make a decision based on performance as to which approaches are most promising for further research and development. The lack of evaluation leaves...successively more difficult problems. This approach might be compared to children taking achievement tests in school. A 90% score on problems involving

Refusing to Leave Desegregation Behind: From Graduates of Racially Diverse Schools to the Supreme Court

ERIC Educational Resources Information Center

Wells, Amy Stuart; Duran, Jacquelyn; White, Terrenda

2008-01-01

Background/Context: In light of the June 2007 U.S. Supreme Court decision in the Louisville and Seattle voluntary school desegregation cases, making it more difficult for district officials to racially balance their schools, this article presents an analysis of prior research on the long-term effects of attending racially diverse schools on their…

Fire, Earth and Wind: Managing Risk in Today's Schools Part 2--The Environment

ERIC Educational Resources Information Center

Weeks, Richard

2010-01-01

Because school business officials are pushed to make difficult decisions quickly when it comes to risk management, they should be aware of the issues associated with environmental safety. School business officials are integral members of the teams that handle crises--big and small--in the school district. A crisis may be as straightforward as the…

Controversies and Decision Making in Difficult Economic Times. New Directions for Community Colleges, Number 53.

ERIC Educational Resources Information Center

Dziech, Billie Wright, Ed.

1986-01-01

The essays in this collection provide contrasting points of view on a number of community college issues that have become more pressing during periods of economic constraint. The volume contains: (1) "Part-Time Faculty: The Value of the Resource," by William R. C. Munsey; (2) "Part-Time Faculty, Full-Time Problems," by David Hartleb and William…

Accelerating Innovation, Competitiveness and Prosperity: Proposal for 2010-2011 Federal Budget Presented to the Honourable James Flaherty, Minister of Finance

ERIC Educational Resources Information Center

Association of Canadian Community Colleges, 2009

2009-01-01

As the country emerges from the recession, the Government of Canada must make difficult but critical decisions about where to invest public resources. Federal investments in research are overwhelmingly directed to pure or discovery research, with little support to applied research tied to commercialization. Innovation for the marketplace and the…

Choosing a Secondary School for Young People on the Autism Spectrum: A Multi-Informant Study

ERIC Educational Resources Information Center

McNerney, Catherine; Hill, Vivian; Pellicano, Elizabeth

2015-01-01

Deciding on a secondary school for children with autism is notoriously difficult for parents. While current UK legislation emphasises the choice that parents of children with special educational needs should have in educational decision-making, there is a dearth of research in this area, which means that little is known about how parents come to…

Prioritizing parts from cutting bills when gang-ripping first

Treesearch

R. Edward Thomas

1996-01-01

Computer optimization of gang-rip-first processing is a difficult problem when working with specific cutting bills. Interactions among board grade and size, arbor setup, and part sizes and quantities greatly complicate the decision making process. Cutting the wrong parts at any moment will mean that more board footage will be required to meet the bill. Using the ROugh...

Evolving Spaces in Landscape Management: Linking Spatial Information for Effective Decision-Making

ERIC Educational Resources Information Center

Ravindranath, R.; Singh, Subrata

2005-01-01

Community, in the policy context, is defined on the basis of fixed in place socio-political unit having residential proximity to the resource or according to state recognized political units. With the boundaries drawn at the village level and the custodial rights of the common lands vested with various departments of the state, it is difficult on…

Choosing to Major in Physics, or Not: Factors Affecting Undergraduate Decision Making

ERIC Educational Resources Information Center

Stiles-Clarke, Laura; MacLeod, Katarin

2016-01-01

For the past 40 years, there has been apprehension in North American society, and particularly in the scientific community, concerning the decline of interest and enrollment in science degree programs at the post-secondary level. This trend has proven very difficult to reverse. The purpose of this study was to explore why students at an Atlantic…

Supreme Court to Hear Case that Could Limit Sex-Bias Claims against Colleges

ERIC Educational Resources Information Center

Kelderman, Eric

2008-01-01

This article reports that the U.S. Supreme Court is scheduled to hear arguments in December in a case that could make it more difficult for plaintiffs to win sexual-discrimination or sexual-harassment lawsuits against colleges and other educational institutions. The justices will decide whether to uphold a decision of the U.S. Court of Appeals for…

Involving Teachers in Data-Driven Decision Making: Using Computer Data Systems to Support Teacher Inquiry and Reflection

ERIC Educational Resources Information Center

Wayman, Jeffrey C.

2005-01-01

Accountability mandates such as No Child Left Behind (NCLB) have drawn attention to the practical use of student data for school improvement. Nevertheless, schools may struggle with these mandates because student data are often stored in forms that are difficult to access, manipulate, and interpret. Such access barriers additionally preclude the…

Keeping wilderness wild: increasing effectiveness with limited resources

Treesearch

Linda Merigliano; Bryan Smith

2000-01-01

Wilderness managers are forced to make increasingly difficult decisions about where to focus limited resources. Traditionally, areas of high visitor use and high impact are prioritized over areas of light use and light impact. However, areas that contain little to no human impact and contain the qualities that lead to the area’s designation as wilderness are most...

Districts' Efforts for Data Use and Computer Data Systems: The Role of Sensemaking in System Use and Implementation

ERIC Educational Resources Information Center

Cho, Vincent; Wayman, Jeffrey C.

2014-01-01

Background: Increasingly, teachers and other educators are expected to leverage data in making educational decisions. Effective data use is difficult, if not impossible, without computer data systems. Nonetheless, these systems may be underused or even rejected by teachers. One potential explanation for such troubles may relate to how teachers…

Neuro-Oncology Branch patient emotional support services | Center for Cancer Research

Cancer.gov

Emotional Support Services The diagnosis of a brain tumor elicits many different and sometimes difficult emotions, not only for the patient, but also for their family members. Patients may encounter changes in cognitive functioning and language, a diminished ability to focus or make decisions, or short-term memory loss, all of which can greatly affect their personal and

Prefrontal Cortical Inactivations Decrease Willingness to Expend Cognitive Effort on a Rodent Cost/Benefit Decision-Making Task.

PubMed

Hosking, Jay G; Cocker, Paul J; Winstanley, Catharine A

2016-04-01

Personal success often necessitates expending greater effort for greater reward but, equally important, also requires judicious use of our limited cognitive resources (e.g., attention). Previous animal models have shown that the prelimbic (PL) and infralimbic (IL) regions of the prefrontal cortex (PFC) are not involved in (physical) effort-based choice, whereas human studies have demonstrated PFC contributions to (mental) effort. Here, we utilize the rat Cognitive Effort Task (rCET) to probe PFC's role in effort-based decision making. In the rCET, animals can choose either an easy trial, where the attentional demand is low but the reward (sugar) is small or a difficult trial on which both the attentional demand and reward are greater. Temporary inactivation of PL and IL decreased all animals' willingness to expend mental effort and increased animals' distractibility; PL inactivations more substantially affected performance (i.e., attention), whereas IL inactivations increased motor impulsivity. These data imply that the PFC contributes to attentional resources, and when these resources are diminished, animals shift their choice (via other brain regions) accordingly. Thus, one novel therapeutic approach to deficits in effort expenditure may be to focus on the resources that such decision making requires, rather than the decision-making process per se. © The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Physician-assisted suicide and euthanasia: disproportionate prevalence of women among Kevorkian's patients.

PubMed

Solomon, Louis M; Noll, Rebekka C

2008-06-01

End-of-life decisions are among the most difficult to make or study. When we examined these decisions made under the auspices and protection of stringent state laws, we found no gender bias among patients who chose to end their lives in the face of documented debilitating and terminal diseases. However, in the case of euthanasia as practiced by Jack Kevorkian, we found significant statistical bias against women. Moreover, other data have questioned whether all of Kevorkian's patients did, in fact, have debilitating and terminal illnesses. In this article, we explore why a gender disparity exists in end-of-life decision making. We conclude that if physician-assisted suicide and euthanasia are to be integrated into any end-of-life medical care policy, stringent legal and medical safeguards will be required. Institution of these safeguards should prevent selection bias in a vulnerable population hastening death for reasons other than medically justifiable conditions or issues of individual autonomy, and should ensure that end-of-life decisions are truly reflective of competent personal choice, free from economic considerations or societal pressure.

Diagnostic approach of myocarditis: strike the golden mean.

PubMed

Hazebroek, M R; Everaerts, K; Heymans, S

2014-02-01

Myocarditis is a challenging diagnosis due to the extreme diversity of clinical manifestations. The actual incidence of myocarditis is also difficult to determine as endomyocardial biopsy (EMB), the diagnostic gold standard, is used infrequently. Nevertheless, in up to 30 % of patients with biopsy-proven myocarditis, progression to dilated cardiomyopathy (DCM) can occur and is associated with a poor prognosis. Recent position statements of the European Society of Cardiology (ESC) and the American Heart Association vary widely with regard to indications for performing an EMB in these patients. This makes decision-making, in particular for general practitioners (GPs) and regional hospitals, difficult and unclear. Therefore, we will present a short summary of the ESC Working Group on Myocardial and Pericardial Diseases statement and our suggestions for GPs and regional hospitals for the diagnostic approach in patients with suspected myocarditis.

Adaptation by Stealth: Understanding climate information use across scales and decision spaces in water management in the United States

NASA Astrophysics Data System (ADS)

Kirchhoff, C.; Vang Rasmussen, L.; Lemos, M. C.

2016-12-01

While there has been considerable focus on understanding how factors related to the creation of climate knowledge affect its uptake and use, less attention has been paid to the actors, decisions, and processes through which climate information supports, or fails to support, action. This is particularly the case concerning how different scales of decision-making influence information uptake. In this study, we seek to understand how water and resource managers' decision space influences climate information use in two Great Lakes watersheds. We find that despite the availability of tailored climate information, actual use of information in decision making remains low. Reasons include: a) lack of willingness to place climate on agendas because local managers perceive climate change as politically risky and a difficult and intangible problem; b) lack of formal mandate or authority at the city and county scale to translate climate information into on-the-ground action, c) problems with the information itself, and d) perceived lack of demand for climate information by those managers who have the mandate and authority (e.g. at the state level) to use (or help others use) climate information. Our findings suggest that 1) climate scientists and information brokers should produce information that meets a range of decision needs and reserve intensive tailoring efforts for decision makers who have authority and willingness to employ climate information, 2) without support from higher levels of decision-making (e.g. state) it is unlikely that climate information use for adaptation decisions will accelerate significantly in the next few years, and 3) the trend towards adopting more sustainability and resilience practices over climate-specific actions should be supported as an important component of the climate adaptation repertoire.

An investigation of the factors effecting high-risk individuals’ decision-making about prophylactic total gastrectomy and surveillance for hereditary diffuse gastric cancer (HDGC)

PubMed Central

Hallowell, Nina; Badger, Shirlene; Richardson, Sue; Caldas, Carlos; Hardwick, Richard H.; Fitzgerald, Rebecca C.; Lawton, Julia

2018-01-01

Because Hereditary Diffuse Gastric Cancer (HDGC) has an early onset and poor prognosis, individuals who carry a pathogenic (CDH1) mutation in the E-cadherin gene (CDH1) are offered endoscopic surveillance and advised to undergo prophylactic total gastrectomy (PTG) in their early to mid-twenties. Patients not ready or fit to undergo gastrectomy, or in whom the genetic testing result is unknown or ambiguous, are offered surveillance. Little is known about the factors that influence decisions to undergo or decline PTG, making it difficult to provide optimal support for those facing these decisions. Qualitative interviews were carried out with 35 high-risk individuals from the Familial Gastric Cancer Study in the UK. Twenty-seven had previously undergone PTG and eight had been identified as carrying a pathogenic CDH1 mutation but had declined surgery at the time of interview. The interviews explored the experience of decision-making and factors influencing risk-management decisions. The data suggest that decisions to proceed with PTG are influenced by a number of potentially competing factors: objective risk confirmation by genetic testing and/or receiving a positive biopsy; perceived familial cancer burden and associated risk perceptions; perceptions of post-surgical life; an increasing inability to tolerate endoscopic procedures; a concern that surveillance could miss a cancer developing and individual’s life stage. These findings have implications for advising this patient group. PMID:27256430

"It Was the Best Decision of My Life": a thematic content analysis of former medical tourists' patient testimonials.

PubMed

Hohm, Carly; Snyder, Jeremy

2015-01-22

Medical tourism is international travel with the intention of receiving medical care. Medical tourists travel for many reasons, including cost savings, limited domestic access to specific treatments, and interest in accessing unproven interventions. Medical tourism poses new health and safety risks to patients, including dangers associated with travel following surgery, difficulty assessing the quality of care abroad, and complications in continuity of care. Online resources are important to the decision-making of potential medical tourists and the websites of medical tourism facilitation companies (companies that may or may not be affiliated with a clinic abroad and help patients plan their travel) are an important source of online information for these individuals. These websites fail to address the risks associated with medical tourism, which can undermine the informed decision-making of potential medical tourists. Less is known about patient testimonials on these websites, which can be a particularly powerful influence on decision-making. A thematic content analysis was conducted of patient testimonials hosted on the YouTube channels of four medical tourism facilitation companies. Five videos per company were viewed. The content of these videos was analyzed and themes identified and counted for each video. Ten main themes were identified. These themes were then grouped into three main categories: facilitator characteristics (e.g., mentions of the facilitator by name, reference to the price of the treatment or to cost savings); service characteristics (e.g., the quality and availability of the surgeon, the quality and friendliness of the support staff); and referrals (e.g., referrals to other potential medical tourists). These testimonials were found either not to mention risks associated with medical tourism or to claim that these risks can be effectively managed through the use of the facilitation company. The failure fully to address the risks of medical tourism can undermine the informed decision-making of potential medical tourists, particularly given the considerable influence on decision-making by patient testimonials. Regulation of these global companies is difficult, making the development of testimonials highlighting the risks of medical tourism essential. Additional research is needed on the impact of patient testimonial videos on the decision-making of potential medical tourists.

Can Classification Tree Analyses Help Improve Decision Making About Treatments for Depression and Anxiety Disorders? A Preliminary Investigation

PubMed Central

Rhodes, Louisa; Naumann, Ulrike M.

2011-01-01

Objective: To identify how decisions about treatment are being made in secondary services for anxiety disorders and depression and, specifically, whether it was possible to predict the decisions to refer for evidence-based treatments. Method: Post hoc classification tree analysis was performed using a sample from an audit on implementation of the National Institute for Health and Clinical Excellence Guidelines for Depression and Anxiety Disorders. The audit was of 5 teams offering secondary care services; they included psychiatrists, psychologists, community psychiatric nurses, social workers, dual-diagnosis workers, and vocational workers. The patient sample included all of those with a primary problem of depression (n = 56) or an anxiety disorder (n = 16) who were offered treatment from February 16 to April 3, 2009. The outcome variable was whether or not evidence-based treatments were offered, and the predictor variables were presenting problem, risk, comorbid problem, social problems, and previous psychiatric history. Results: Treatment decisions could be more accurately predicted for anxiety disorders (93% correct) than for depression (55%). For anxiety disorders, the presence or absence of social problems was a good predictor for whether evidence-based or non–evidence-based treatments were offered; 44% (4/9) of those with social problems vs 100% (6/6) of those without social problems were offered evidence-based treatments. For depression, patients’ risk rating had the largest impact on treatment decisions, although no one variable could be identified as individually predictive of all treatment decisions. Conclusions: Treatment decisions were generally consistent for anxiety disorders but more idiosyncratic for depression, making the development of a decision-making model very difficult for depression. The lack of clarity of some terms in the clinical guidelines and the more complex nature of depression could be factors contributing to this difficulty. Further research is needed to understand the complex nature of decision making with depressed patients. PMID:22295255

Expert Recommendations on Treating Psoriasis in Special Circumstances (Part II).

PubMed

Carrascosa, J M; Galán, M; de Lucas, R; Pérez-Ferriols, A; Ribera, M; Yanguas, I

2016-11-01

There is insufficient information on how best to treat moderate to severe psoriasis in difficult clinical circumstances. We considered 5 areas where there is conflicting or insufficient evidence: pediatric psoriasis, risk of infection in patients being treated with biologics, psoriasis in difficult locations, biologic drug survival, and impact of disease on quality of life. Following discussion of the issues by an expert panel of dermatologists specialized in the management of psoriasis, participants answered a questionnaire survey according to the Delphi method. Consensus was reached on 66 (70.9%) of the 93 items analyzed; the experts agreed with 49 statements and disagreed with 17. It was agreed that body mass index, metabolic comorbidities, and quality of life should be monitored in children with psoriasis. The experts also agreed that the most appropriate systemic treatment for this age group was methotrexate, while the most appropriate biologic treatment was etanercept. Although it was recognized that the available evidence was inconsistent and difficult to extrapolate, the panel agreed that biologic drug survival could be increased by flexible, individualized dosing regimens, continuous treatment, and combination therapies. Finally, consensus was reached on using the Dermatology Quality of Life Index to assess treatment effectiveness and aid decision-making in clinical practice. The structured opinion of experts guides decision-making regarding aspects of clinical practice for which there is incomplete or conflicting information. Copyright © 2016 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.

Moral education for nursing decisions.

PubMed

van Hooft, S

1990-02-01

This paper attacks the Kantian conception of mortality that predominates in our society and the rationalist educational strategies that flow from it. In its place it offers an Aristotelian conception of ethics in which sensitivity and feeling are important components of practical reason. It argues that a nurse's ethical concerns extend further than the several moral dilemmas discussed in the daily press and that those concerns should be responded to in moral education by a process called 'empowerment'. Empowerment seeks to develop confidence and sensitivity in the making of difficult decisions and does so by training habits, developing attitudes, and encouraging reflection on actions performed.

Oocyte Cryopreservation for Fertility Preservation in Healthy Women.

PubMed

Stevenson, Eleanor L; Hurt, Melissa J; Trotter, Kathryn J

Advancements in methods of fertility preservation have resulted in more options available to women seeking to postpone reproduction. Preservation of unfertilized oocytes provides women with the possibility for reproduction even after age-related declines in fertility might make conceiving a child difficult to impossible. As oocyte cryopreservation rises in popularity among women, it is crucial for nurses and other clinicians to understand the background, process, ethical issues, and risks involved to help women make informed medical decisions. © 2017 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses.

Important medical decisions: Using brief motivational interviewing to enhance patients' autonomous decision-making.

PubMed

Pantalon, Michael V; Sledge, William H; Bauer, Stephen F; Brodsky, Beth; Giannandrea, Stephanie; Kay, Jerald; Lazar, Susan G; Mellman, Lisa A; Offenkrantz, William C; Oldham, John; Plakun, Eric M; Rockland, Lawrence H

2013-03-01

The use of motivational interviewing (MI) when the goals of patient and physician are not aligned is examined. A clinical example is presented of a patient who, partly due to anxiety and fear, wants to opt out of further evaluation of his hematuria while the physician believes that the patient must follow up on the finding of hematuria. As patients struggle in making decisions about their medical care, physician interactions can become strained and medical care may become compromised. Physicians sometimes rely on their authority within the doctor-patient relationship to assist patients in making decisions. These methods may be ineffective when there is a conflict in motivations or goals, such as with patient ambivalence and resistance. Furthermore, the values of patient autonomy may conflict with the values of beneficence. A patient simulation exercise is used to demonstrate the value of MI in addressing the motivations of a medical patient when autonomy is difficult to realize because of a high level of resistance to change due to fear. The salience of MI in supporting the value of patient autonomy without giving up the value of beneficence is discussed by providing a method of evaluating the patient's best interests by psychotherapeutically addressing his anxious, fear-based ambivalence.

Tick-Tock Goes the Croc: A High-Density EEG Study of Risk-Reactivity and Binge-Drinking.

PubMed

Kiat, John E; Cheadle, Jacob E

2018-05-31

Links between individual differences in risk processing and high-risk behaviors such as binge drinking have long been the focus of active research. However, investigations in this area almost exclusively utilize decision-making focused paradigms. This emphasis makes it difficult to assess links between risk behaviors and raw risk reactivity independent of decision and feedback processes. A deeper understanding of this association has the potential to shed light on the role of risk reactivity in high-risk behavior susceptibility. To contribute towards this aim, this study utilizes a popular risk-taking game, the crocodile dentist, to assess links between individual differences in decision-free risk-reactivity and reported binge drinking frequency levels. In this task, participants engage in a series of decision-free escalating risk responses. Risk-reactivity was assessed by measuring Late Positive Potential responses towards risk-taking action initiation cues using high-density 256-Channel EEG. The results indicate that, after controlling for overall alcohol consumption frequency, higher rates of reported binge drinking are associated with both increased general risk-taking responsivity and increased risk-reactivity escalation as a function of risk level. These findings highlight intriguing links between risk reactivity and binge drinking frequency, making key contributions in the areas of risk-taking and affective science.

The Difficult Airway Society 'ADEPT' guidance on selecting airway devices: the basis of a strategy for equipment evaluation.

PubMed

Pandit, J J; Popat, M T; Cook, T M; Wilkes, A R; Groom, P; Cooke, H; Kapila, A; O'Sullivan, E

2011-08-01

Faced with the concern that an increasing number of airway management devices were being introduced into clinical practice with little or no prior evidence of their clinical efficacy or safety, the Difficult Airway Society formed a working party (Airway Device Evaluation Project Team) to establish a process by which the airway management community within the profession could itself lead a process of formal device/equipment evaluation. Although there are several national and international regulations governing which products can come on to the market and be legitimately sold, there has hitherto been no formal professional guidance relating to how products should be selected (i.e. purchased). The Airway Device Evaluation Project Team's first task was to formulate such advice, emphasising evidence-based principles. Team discussions led to a definition of the minimum level of evidence needed to make a pragmatic decision about the purchase or selection of an airway device. The Team concluded that this definition should form the basis of a professional standard, guiding those with responsibility for selecting airway devices. We describe how widespread adoption of this professional standard can act as a driver to create an infrastructure in which the required evidence can be obtained. Essential elements are that: (i) the Difficult Airway Society facilitates a coherent national network of research-active units; and (ii) individual anaesthetists in hospital trusts play a more active role in local purchasing decisions, applying the relevant evidence and communicating their purchasing decisions to the Difficult Airway Society. © 2011 The Authors. Anaesthesia © 2011 The Association of Anaesthetists of Great Britain and Ireland.

Pig farmers' perceptions, attitudes, influences and management of information in the decision-making process for disease control.

PubMed

Alarcon, Pablo; Wieland, Barbara; Mateus, Ana L P; Dewberry, Chris

2014-10-01

The objectives of this study were (1) to explore the factors involved in the decision-making process used by pig farmers for disease control and (2) to investigate pig farmers' attitudes and perceptions about different information sources relating to disease control. In 2011 a qualitative study involving 20 face-to-face interviews with English pig farmers was conducted. The questionnaire was composed of three parts. The first part required farmers to identify two diseases they had experienced and which were difficult to recognize and/or control. They were asked to report how the disease problem was recognized, how the need for control was decided, and what affected the choice of control approach. For the latter, a structure related to the Theory of Planned Behaviour was used. Their verbal responses were classified as associated with: (1) attitude and beliefs, (2) subjective norms, or (3) perceived behavioural control (PBC). In the second part, five key sources of information for disease control (Defra, BPEX, research from academia, internet and veterinarians) and the factors related to barriers to knowledge were investigated. Interviews were recorded and transcribed. A qualitative analysis of the text of the interview transcripts was carried out using templates. Drivers for disease control were 'pig mortality', 'feeling of entering in an economically critical situation', 'animal welfare' and 'feeling of despair'. Veterinarians were perceived by several participating farmers as the most trusted information source on disease control. However, in particular non-sustainable situations, other producers, and especially experiences from abroad, seemed to considerably influence the farmers' decision-making. 'Lack of knowledge', 'farm structure and management barriers' and 'economic constrains' were identified in relation to PBC. Several negative themes, such as 'lack of communication', 'not knowing where to look', and 'information bias' were associated with research from academia. This study identified a range of factors influencing the decision-making process for disease control by pig farmers. In addition, it highlighted the lack of awareness and difficult access of producers to current scientific research outputs. The factors identified should be considered when developing communication strategies to disseminate research findings and advice for disease control. Copyright © 2013 Elsevier B.V. All rights reserved.

Involved, inputting or informing: "Shared" decision making in adult mental health care.

PubMed

Bradley, Eleanor; Green, Debra

2018-02-01

A diagnosis of serious mental illness can impact on the whole family. Families informally provide significant amounts of care but are disproportionately at risk of carer burden when compared to those supporting people with other long-term conditions. Shared decision making (SDM) is an ethical model of health communication associated with positive health outcomes; however, there has been little research to evaluate how routinely family is invited to participate in SDM, or what this looks like in practice. This UK study aimed to better understand how the family caregivers of those diagnosed with SMI are currently involved in decision making, particularly decisions about treatment options including prescribed medication. Objectives were to Explore the extent to which family members wish to be involved in decisions about prescribed medication Determine how and when professionals engage family in these decisions Identify barriers and facilitators associated with the engagement of family in decisions about treatment. Open-ended questions were sent to professionals and family members to elicit written responses. Qualitative responses were analysed thematically. Themes included the definition of involvement and "rules of engagement." Staff members are gatekeepers for family involvement, and the process is not democratic. Family and staff ascribe practical, rather than recovery-oriented roles to family, with pre-occupation around notions of adherence. Staff members need support, training and education to apply SDM. Time to exchange information is vital but practically difficult. Negotiated teams, comprising of staff, service users, family, peers as applicable, with ascribed roles and responsibilities could support SDM. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Human due diligence.

PubMed

Harding, David; Rouse, Ted

2007-04-01

Most companies do a thorough job of financial due diligence when they acquire other companies. But all too often, deal makers simply ignore or underestimate the significance of people issues in mergers and acquisitions. The consequences are severe. Most obviously, there's a high degree of talent loss after a deal's announcement. To make matters worse, differences in decision-making styles lead to infighting; integration stalls; and productivity declines. The good news is that human due diligence can help companies avoid these problems. Done early enough, it helps acquirers decide whether to embrace or kill a deal and determine the price they are willing to pay. It also lays the groundwork for smooth integration. When acquirers have done their homework, they can uncover capability gaps, points of friction, and differences in decision making. Even more important, they can make the critical "people" decisions-who stays, who goes, who runs the combined business, what to do with the rank and file-at the time the deal is announced or shortly thereafter. Making such decisions within the first 30 days is critical to the success of a deal. Hostile situations clearly make things more difficult, but companies can and must still do a certain amount of human due diligence to reduce the inevitable fallout from the acquisition process and smooth the integration. This article details the steps involved in conducting human due diligence. The approach is structured around answering five basic questions: Who is the cultural acquirer? What kind of organization do you want? Will the two cultures mesh? Who are the people you most want to retain? And how will rank-and-file employees react to the deal? Unless an acquiring company has answered these questions to its satisfaction, the acquisition it is making will be very likely to end badly.

Family-centered end-of-life care in the ICU.

PubMed

Wiegand, Debra L; Grant, Marian S; Cheon, Jooyoung; Gergis, Mary A

2013-08-01

Families of older adults are intricately involved in the end-of-life decision-making process for a family member with a serious illness in the intensive care unit (ICU) setting. However, families are not always as involved and as informed as they would like to be. Creating a culture that assesses family needs and supports families is an important component of family-centered care. There are several strategies that nurses and other members of the interdisciplinary team can use to promote family-centered end-of-life care in the ICU. Nurses can get to know the family by spending time talking with them, assessing them, seeking to understand their perspectives on their family member's condition, and discussing previously verbalized patient wishes for care. This article offers strategies nurses can use to help guide the family through the end-of-life decision-making process, support families as difficult and complex decisions are made in collaboration with the health care team, and prepare families for the dying process. Copyright 2013, SLACK Incorporated.

Constraint reasoning in deep biomedical models.

PubMed

Cruz, Jorge; Barahona, Pedro

2005-05-01

Deep biomedical models are often expressed by means of differential equations. Despite their expressive power, they are difficult to reason about and make decisions, given their non-linearity and the important effects that the uncertainty on data may cause. The objective of this work is to propose a constraint reasoning framework to support safe decisions based on deep biomedical models. The methods used in our approach include the generic constraint propagation techniques for reducing the bounds of uncertainty of the numerical variables complemented with new constraint reasoning techniques that we developed to handle differential equations. The results of our approach are illustrated in biomedical models for the diagnosis of diabetes, tuning of drug design and epidemiology where it was a valuable decision-supporting tool notwithstanding the uncertainty on data. The main conclusion that follows from the results is that, in biomedical decision support, constraint reasoning may be a worthwhile alternative to traditional simulation methods, especially when safe decisions are required.

Limbic Justice—Amygdala Involvement in Immediate Rejection in the Ultimatum Game

PubMed Central

Fransson, Peter; Petrovic, Predrag; Johannesson, Magnus; Ingvar, Martin

2011-01-01

Imaging studies have revealed a putative neural account of emotional bias in decision making. However, it has been difficult in previous studies to identify the causal role of the different sub-regions involved in decision making. The Ultimatum Game (UG) is a game to study the punishment of norm-violating behavior. In a previous influential paper on UG it was suggested that frontal insular cortex has a pivotal role in the rejection response. This view has not been reconciled with a vast literature that attributes a crucial role in emotional decision making to a subcortical structure (i.e., amygdala). In this study we propose an anatomy-informed model that may join these views. We also present a design that detects the functional anatomical response to unfair proposals in a subcortical network that mediates rapid reactive responses. We used a functional MRI paradigm to study the early components of decision making and challenged our paradigm with the introduction of a pharmacological intervention to perturb the elicited behavioral and neural response. Benzodiazepine treatment decreased the rejection rate (from 37.6% to 19.0%) concomitantly with a diminished amygdala response to unfair proposals, and this in spite of an unchanged feeling of unfairness and unchanged insular response. In the control group, rejection was directly linked to an increase in amygdala activity. These results allow a functional anatomical detection of the early neural components of rejection associated with the initial reactive emotional response. Thus, the act of immediate rejection seems to be mediated by the limbic system and is not solely driven by cortical processes, as previously suggested. Our results also prompt an ethical discussion as we demonstrated that a commonly used drug influences core functions in the human brain that underlie individual autonomy and economic decision making. PMID:21559322

Collaborative Platforms Aid Emergency Decision Making

NASA Technical Reports Server (NTRS)

2013-01-01

Terra. Aqua. Cloudsat. Landsat. NASA runs and partners in many missions dedicated to monitoring the Earth, and the tools used in these missions continuously return data on everything from shifts in temperature to cloud formation to pollution levels over highways. The data are of great scientific value, but they also provide information that can play a critical role in decision making during times of crisis. Real-time developments in weather, wind, ocean currents, and numerous other conditions can have a significant impact on the way disasters, both natural and human-caused, unfold. "NASA has long recognized the need to make its data from real-time sources compatible and accessible for the purposes of decision making," says Michael Goodman, who was Disasters Program manager at NASA Headquarters from 2009-2012. "There are practical applications of NASA Earth science data, and we d like to accelerate the use of those applications." One of the main obstacles standing in the way of eminently practical data is the fact that the data from different missions are collected, formatted, and stored in different ways. Combining data sets in a way that makes them useful for decision makers has proven to be a difficult task. And while the need for a collaborative platform is widely recognized, very few have successfully made it work. Dave Jones, founder and CEO of StormCenter Communications Inc., which consults with decision makers to prepare for emergencies, says that "when I talk to public authorities, they say, If I had a nickel for every time someone told me they had a common operating platform, I d be rich. But one thing we ve seen over the years is that no one has been able to give end users the ability to ingest NASA data sets and merge them with their own."

What Factors Do Allied Health Take Into Account When Making Resource Allocation Decisions?

PubMed Central

Lane, Haylee; Sturgess, Tamica; Philip, Kathleen; Markham, Donna; Martin, Jennifer; Walsh, Jill; Hubbard, Wendy; Haines, Terry

2018-01-01

Background: Allied health comprises multiple professional groups including dietetics, medical radiation practitioners, occupational therapists, optometrists and psychologists. Different to medical and nursing, Allied health are often organized in discipline specific departments and allocate budgets within these to provide services to a range of clinical areas. Little is known of how managers of allied health go about allocating these resources, the factors they consider when making these decisions, and the sources of information they rely upon. The purpose of this study was to identify the key factors that allied health consider when making resource allocation decisions and the sources of information they are based upon. Methods: Four forums were conducted each consisting of case studies, a large group discussion and two hypothetical scenarios to elicit data. A thematic content analysis commenced during post-forum discussions of key factors by forum facilitators. These factors were then presented to an expert working party for further discussion and refinement. Transcripts were generated of all data recordings and a detailed thematic analysis was undertaken by one author to ensure coded data matched the initial thematic analysis. Results: Twelve factors affecting the decision-making of allied health managers and clinicians were identified. One of these factors was disendorsed by the expert working party. The 11 remaining factors can be considered to be key decision-making principles that should be consistently applied to resource allocation. These principles were clustered into three overarching themes of readiness, impact and appropriateness. Conclusion: Understanding these principles now means further research can be completed to more effectively integrate research evidence into health policy and service delivery, create partnerships among policy-makers, managers, service providers and researchers, and to provide support to answer difficult questions that policy-makers, managers and service providers face. PMID:29764105

Public participation and environmental impact assessment: Purposes, implications, and lessons for public policy making

DOE Office of Scientific and Technical Information (OSTI.GOV)

O'Faircheallaigh, Ciaran, E-mail: Ciaran.Ofaircheallaigh@griffith.edu.a

In recent years the need to enhance public participation in Environmental Impact Assessment (EIA), and the efficacy of alternative mechanisms in achieving this goal, have been central themes in the EIA literature. The benefits of public participation are often taken for granted, and partly for this reason the underlying rationale for greater public participation is sometimes poorly articulated, making it more difficult to determine how to pursue it effectively. The reasons for seeking public participation are also highly diverse and not always mutually consistent. There has been limited analysis of the implications of different forms and degrees of public participationmore » for public decision making based on EIA, and little discussion of how experience with public participation in EIA relates to debates about participation in policy making generally. This paper distinguishes various purposes for public participation in EIA, and discusses their implications for decision making. It then draws on some general models of public participation in policy making to consider how approaches to participation in EIA can be interpreted and valued, and asks what EIA experience reveals about the utility of these models. It argues that the models pay insufficient attention to the interaction that can occur between different forms of public participation; and to the fact that public participation raises issues regarding control over decision making that are not subject to resolution, but must be managed through ongoing processes of negotiation.« less

Shared Decision Making in Common Chronic Conditions: Impact of a Resident Training Workshop.

PubMed

Simmons, Leigh; Leavitt, Lauren; Ray, Alaka; Fosburgh, Blair; Sepucha, Karen

2016-01-01

Physicians must be competent in several different kinds of communication skills in order to implement shared decision making; however, these skills are not part of routine medical student education, nor are they formally taught during residency training. We developed a 1- and 2-hour workshop curriculum for internal medicine residents to promote shared decision making in treatment decisions for four common chronic conditions: diabetes, depression, hypertension, and hyperlipidemia. The workshops included a written case exercise, a short didactic presentation on shared decision-making concepts and strategies for risk communication, and two role-playing exercises focused on decision making for depression and hyperlipidemia treatment. We delivered the workshop as a required component of the resident curriculum in ambulatory medicine. To evaluate the impact of the workshop, we used written course evaluations, tracked the use of the newly introduced Decision Worksheets, and asked preceptors to perform direct observation of treatment decision conversations. Residents were involved in the development of the workshop and helped identify key content, suggested framing for difficult topics, and confirmed the need for the skills workshop. One hundred thirty internal medicine and medicine-pediatrics residents attended 8 workshops over a 4-month period. In written cases completed before the workshop, the majority of residents indicated that they would discuss medications, but few mentioned other treatment options or documented patients' goals and preferences in a sample encounter note with a patient with new depression symptoms. Overall, most participants (89.7%) rated the workshop as excellent or very good, and 93.5% said that they would change their practice based on what they learned. Decision Worksheets addressing diabetes, depression, hyperlipidemia, and hypertension were available on a primary care-focused intranet site and were downloaded almost 1,200 times in the first 8 months following the workshops. Preceptors were able to observe only one consult during which one of the four topics was discussed. Internal medicine residents had considerable gaps in shared decision-making skills as measured in a baseline written exercise. Residents provided valuable contributions to the development of a Decision Worksheet to be used at the point of care. Participants rated the skills workshop highly, though interns rated the exercise more useful than PGY-2 and PGY-3 residents did. The Decision Worksheets were accessed often following the sessions; however, observing the Decision Worksheets in use in real time was a challenge in the resident-faculty clinic. Additional studies are warranted to examine whether the workshop was successful in increasing residents' ability to implement skills in practice.

Economic evaluation of preventive dental programs: what can they tell us?

PubMed

Morgan, Mike; Mariño, Rodrigo; Wright, Clive; Bailey, Denise; Hopcraft, Matthew

2012-10-01

The role of public health program planners is to determine the effectiveness of public health programs, what recommendations should be made, what future initiatives should be taken, and what policies should be developed. At a basic level, to choose between competing alternatives, two characteristics of an intervention must be considered; these are its outcome and its cost. Based on cost and outcome, planners must select the option that offers the most advantages. Economic evaluation is commonly adopted by decision makers in the health sector to investigate the effectiveness of public health programs and to help plan future initiatives. Economic evaluation assists decision makers who must weigh the information it provides in the context of many and often competing options. In this way, an economic evaluation is an aid to decision making rather than the decision itself. Economic evaluation is becoming essential for informed decision making, with potential implications for public health policy and practice and for clinical practice too. While economic evaluations are commonly used in decision-making processes about health programs, few examples exist in the oral health literature. In the case of preventive oral health programs, economic analysis is often difficult, largely because it makes demands on epidemiological and demographic data that are hard to meet. This study will address the concepts and tools required to conduct economic evaluations of prevention programs. The emphasis will be on oral health and preventive dental programs, although the concepts presented could be useful for other public health programs by practitioners and managers with the aim of producing effective and efficient oral health programs. © 2012 John Wiley & Sons A/S.

Decision making in liver transplant selection committees: a multicenter study.

PubMed

Volk, Michael L; Biggins, Scott W; Huang, Mary Ann; Argo, Curtis K; Fontana, Robert J; Anspach, Renee R

2011-10-18

To receive a liver transplant, patients must first be placed on a waiting list-a decision made at most transplant centers by a multidisciplinary committee. The function of these committees has never been studied. To describe decision making in liver transplant committees and identify opportunities for process improvement. Observational multicenter study. 4 liver transplant centers in the United States. 68 members of liver transplant committees across the 4 centers. 63 meetings were observed, and 50 committee members were interviewed. Recorded transcripts and field notes were analyzed by using standard qualitative sociologic methods. Although the structure of the meetings varied by center, the process was uniform and primarily involved inductive reasoning to review possible reasons for patient exclusion. Patients were excluded if they were too well, too sick (in the setting of advanced liver disease), or too old or had nonhepatic comorbid conditions, substance abuse problems, or other psychosocial barriers. Dominant themes in the discussions included member angst over deciding who lived or died, a high correlation between psychosocial barriers to transplantation and the patient's socioeconomic status, and the influence of external forces on decision making. Unwritten center policies and confusion regarding advocacy versus stewardship roles were consistently identified as barriers to effective group decision making. The use of qualitative methods provides broad understanding but limits specific inferences. The 4 centers may not reflect the practices of every transplant center nationwide. The difficult decisions made by liver transplant committees are reasonably consistent and well-intentioned, but the process might be improved by having more explicit written policies and clarifying roles. This may inform resource allocation in other areas of medicine. The Greenwall Foundation and the National Institutes of Health.

Decision Making in Liver Transplant Selection Committees

PubMed Central

Volk, Michael L; Biggins, Scott W; Huang, Mary Ann; Argo, Curtis K; Fontana, Robert J; Anspach, Renee R

2011-01-01

Background In order to receive a liver transplant, patients must first be placed on the waiting list – a decision made in most transplant centers by a multidisciplinary committee. The function of these committees has never been studied. Objectives To describe decision making in liver transplant committees and identify opportunities for process improvement. Design Observational multi-center Setting We observed 63 meetings and interviewed 50 committee members at 4 liver transplant centers. Study Subjects Transplant committee members. Measurements Recorded transcripts and field notes were analyzed using standard qualitative sociological methods. Results While the structure of meetings varied by center, the process was uniform and involved reviewing possible reasons for patient exclusion using primarily inductive reasoning. Stated justifications for excluding patients were a) too well, b) non-hepatic comorbidities or advanced age, c) too sick in the setting of advanced liver disease, d) substance abuse, or e) other psychosocial barriers. Dominant themes identified included members’ angst over deciding who lives and dies, a high correlation between psychosocial barriers to transplant and patients’ socioeconomic status, and the influence of external forces on decision making. Consistently identified barriers to effective group decision making were: 1) unwritten center policies, and 2) confusion regarding advocacy versus stewardship roles. Limitations The use of qualitative methods provides broad understanding but limits specific inferences. These four centers may not be reflective of every transplant center nationwide. Conclusion The difficult decisions made by these committees are reasonably consistent and always well-intentioned, but might be improved by more explicit written policies and clarifying roles. This process may help inform resource allocation in other areas of medicine. Primary funding source The Greenwall Foundation. PMID:22007044

The administrator's quest for quality.

PubMed

Ross, A

1988-01-01

Times are tough and will become even tougher. Retrenchment issues will be foremost in many operational settings. Failure to understand baseline quality standards will make it extremely difficult to know where to cut and how to regroup without adversely affecting patient attitudes and service. Practice patterns are changing rapidly and the astute administrator needs to be prepared to participate freely in decisions affecting quality, service and costs.

The Educational Efficacy of a Values-Based Online Tool in a Public Health Ethics Course

ERIC Educational Resources Information Center

Tripken, Jennifer L.

2016-01-01

Purpose: The purpose of this study was to assess the educational efficacy of an online software decision-making program, The Values Exchange. While ethics is a vital aspect of educating public health professionals, it is both difficult to teach and assess. There is a need to identify best practices in the pedagogy of public health ethics and in…

Management Information Systems Research.

DTIC Science & Technology

Research on management information systems is illusive in many respects. Part of the basic research problem in MIS stems from the absence of standard...decision making. But the transition from these results to the realization of ’satisfactory’ management information systems remains difficult indeed. The...paper discusses several aspects of research on management information systems and reviews a selection of efforts that appear significant for future progress. (Author)

A Key to Evaluation: The Transition Competence Battery for Deaf Adolescents and Young Adults

ERIC Educational Resources Information Center

Davis, Cheryl; Leonard, Annette

2007-01-01

Guiding deaf and hard of hearing students in making important decisions about their adult careers can be a difficult task. Twenty years after its inception, the TCB, as adapted for deaf and hard of hearing students, may help. The TCB is a unique assessment tool designed to measure the transition skills of deaf high school adolescents and young…

Allegiance: Egypt Security Forces

DTIC Science & Technology

2013-12-01

precept that humans are self -interested, an inherent trait of human nature; elements of rational choice theory developed from this initial frame...rebellious collective action.18 This illustrates the impact of the greater collective good, valued at times above an actor’s self -interest, which gained...in a particular manner which is difficult to fit into a self -interest niche. Utility theory’s rationale removes feeling from the decision making

The Impact of State Fiscal Effort on Student Achievement Measured by Math Scores from the National Assessment of Education Progress (NAEP)

ERIC Educational Resources Information Center

Kelly, Lorena LeeAnn

2012-01-01

The current financial state of our nation, in combination with the pressure to meet state accountability testing and a global call for better prepared twenty first century learners, has produced a situation where all levels of government have to make difficult decisions regarding expenditures. In order to ensure that education receives appropriate…

Challenges in Computational Social Modeling and Simulation for National Security Decision Making

DTIC Science & Technology

2011-06-01

This study is grounded within a system-activity theory , a logico-philosophical model of interdisciplinary research [13, 14], the concepts of social...often a difficult challenge. Ironically, social science research methods , such as ethnography , may be tremendously helpful in designing these...social sciences. Moreover, CSS projects draw on knowledge and methods from other fields of study , including graph theory , information visualization

The web-surfing bariatic patient: the role of the internet in the decision-making process.

PubMed

Paolino, Luca; Genser, Laurent; Fritsch, Sylvie; De' Angelis, Nicola; Azoulay, Daniel; Lazzati, Andrea

2015-04-01

Health-related information on the Internet is constantly increasing, but its quality and accountability are difficult to assess. Patients browse the Net to get more information, but the impact of the Internet on their decisions about surgical techniques, referral centers, or surgeon choice are still not clear. This study aimed to describe the role of the Internet in the decision-making process of obese patients seeking bariatric surgery. Two hundred and twelve candidates for bariatric surgery were asked to answer a questionnaire evaluating their access to the Internet, the usefulness and trustworthiness of Internet-retrieved information, the verification of the information, and the role of the information in the decision-making process. Two hundred and twelve patients answered the questionnaire. Of these, 95.1% had access to the Internet and 77.8% reported having researched about bariatric surgery. Their main interests were the surgical techniques (81.4%) and other patients' experiences (72.3%). The favorite Web sites were those affiliated to public hospitals or edited by other patients. The accountability of the e-information was mainly evaluated by discussion with the general practitioner (GP) (83.0%) or family members and friends (46.8%). One patient in four decided to undergo bariatric surgery mainly based on e-information, while discussion about treatment options with the GP and the hospital reputation were taken into account in 77.8 and 51.7% of cases, respectively. Most patients seeking bariatric surgery search for health information online. E-information seems to have an important role in the decision-making process of patients who are candidates for bariatric surgery.

A mixed-methods exploration of the contraceptive experiences of female teens with epilepsy.

PubMed

Manski, Ruth; Dennis, Amanda

2014-09-01

We explored the contraceptive experiences of female teens with epilepsy, including their knowledge and perceptions of interactions between antiepileptic drugs and hormonal contraception and contraceptive decision-making processes. From November 2012 to May 2013, we conducted one online survey (n=114) and 12 online focus group discussions (n=26) with female teens with epilepsy about their contraceptive experiences and unmet needs. Survey data were analyzed using descriptive statistics and focus group transcripts were analyzed thematically using modified grounded theory methods. Both survey and focus group participants reported believing that interactions between epilepsy medications and hormonal contraceptives could lead to reductions in contraceptive efficacy and seizure control. However, their knowledge about these types of medication interactions was often incomplete. Many study participants viewed contraceptive decision making as a difficult process, and some participants reported avoiding hormonal contraceptives because of potential interactions with antiepileptic drugs. Study participants reported relying on health care providers and parents for contraceptive decision-making support. Focus group participants also reported they wanted health care providers to provide more in-depth and comprehensive counseling about contraception, and that they desired peer support with contraceptive decisions. The ability to make informed contraceptive decisions is important for teens with epilepsy as interactions between anti-epileptic drugs and hormonal contraceptives can impact seizure occurrence and lead to an increased risk of unplanned pregnancy. Guidance for providers offering contraceptive care to this population is needed, as well as a contraceptive support tool that empowers teens with epilepsy to advocate for desired health care. Copyright © 2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Lexical Familiarity and Processing Efficiency: Individual Differences in Naming, Lexical Decision, and Semantic Categorization

PubMed Central

Lewellen, Mary Jo; Goldinger, Stephen D.; Pisoni, David B.; Greene, Beth G.

2012-01-01

College students were separated into 2 groups (high and low) on the basis of 3 measures: subjective familiarity ratings of words, self-reported language experiences, and a test of vocabulary knowledge. Three experiments were conducted to determine if the groups also differed in visual word naming, lexical decision, and semantic categorization. High Ss were consistently faster than low Ss in naming visually presented words. They were also faster and more accurate in making difficult lexical decisions and in rejecting homophone foils in semantic categorization. Taken together, the results demonstrate that Ss who differ in lexical familiarity also differ in processing efficiency. The relationship between processing efficiency and working memory accounts of individual differences in language processing is also discussed. PMID:8371087

[How much knowledge do health insurance companies need to make reimbursement decisions?].

PubMed

Pfeiffer, Doris

2009-01-01

Health insurance companies play a very significant role in the sociopolitical context. It is their responsibility to meet the demands of modern health services delivery, while at the same time limited financial resources need to be considered. Difficult decisions have to be made which must take into account the needs of the insured party as well as the healthcare situation and oncoming possibilities. Health insurance companies rely on secure knowledge with a high level of evidence to justify their decisions in a collectively funded healthcare system. Where the elimination of knowledge gaps is not related to the expectation of profit on the part of potential providers of medical services, procedures or products the funding of high-quality studies should be considered.

Neighborhood graph and learning discriminative distance functions for clinical decision support.

PubMed

Tsymbal, Alexey; Zhou, Shaohua Kevin; Huber, Martin

2009-01-01

There are two essential reasons for the slow progress in the acceptance of clinical case retrieval and similarity search-based decision support systems; the especial complexity of clinical data making it difficult to define a meaningful and effective distance function on them and the lack of transparency and explanation ability in many existing clinical case retrieval decision support systems. In this paper, we try to address these two problems by introducing a novel technique for visualizing inter-patient similarity based on a node-link representation with neighborhood graphs and by considering two techniques for learning discriminative distance function that help to combine the power of strong "black box" learners with the transparency of case retrieval and nearest neighbor classification.

Interpersonal Influences and Attitudes about Adjuvant Therapy Treatment Decisions among Early Stage Breast Cancer Patients: An Examination of Differences by Age and Race/Ethnicity in the BQUAL Study

PubMed Central

Shelton, Rachel C.; Hillyer, Grace Clarke; Hershman, Dawn L.; Leoce, Nicole; Kushi, Lawrence H.; Lamerato, Lois; Nathanson, S. David; Ambrosone, Christine B.; Bovbjerg, Dana H.; Mandelblatt, Jeanne S.; Neugut, Alfred I.

2013-01-01

Patients are increasingly involved in cancer treatment decisions and yet little research has explored factors that may affect patient attitudes and beliefs about their therapeutic choices. This paper examines psychosocial factors (e.g., attitudes, social support), provider-related factors (e.g., communication, trust), and treatment considerations in a prospective study of a sample of early stage breast cancer patients eligible for chemotherapy and/or hormonal therapy (BQUAL cohort). The data comes from a multi-site cohort study of white, black, Hispanic, and Asian non-metastatic breast cancer patients recruited in New York City, Northern California, and Detroit Michigan. Baseline surveys were conducted over the telephone between 2006 and 2010 among a total of 1145 women. Most participants were white (68%), had more than a high school education (76%), and were diagnosed with stage I disease (51%). The majority of women reported discussing chemotherapy and hormonal therapy with their doctor (90% and 83% respectively); these discussions primarily took place with medical oncologists. Nearly a quarter of women reported that the treatment decision was difficult and the majority were accompanied to the doctor (76%) and involved a friend or family member in the decision (54%). Positive considerations (e.g., beliefs about treatment reducing risk of recurrence) were important in making treatment decisions. Participants preferred a shared decision-making style, but results suggested that there is room for improvement in terms of actual patient involvement in the decision and provider communication, particularly among black patients. Patients 65 years and older reported fewer provider discussions of chemotherapy, poorer patient-provider communication, higher rates of being assisted by family members in making the decision, and more negative attitudes and beliefs towards treatment. PMID:23263696

Factors influencing malaria control policy-making in Kenya, Uganda and Tanzania.

PubMed

Mutero, Clifford M; Kramer, Randall A; Paul, Christopher; Lesser, Adriane; Miranda, Marie Lynn; Mboera, Leonard E G; Kiptui, Rebecca; Kabatereine, Narcis; Ameneshewa, Birkinesh

2014-08-08

Policy decisions for malaria control are often difficult to make as decision-makers have to carefully consider an array of options and respond to the needs of a large number of stakeholders. This study assessed the factors and specific objectives that influence malaria control policy decisions, as a crucial first step towards developing an inclusive malaria decision analysis support tool (MDAST). Country-specific stakeholder engagement activities using structured questionnaires were carried out in Kenya, Uganda and Tanzania. The survey respondents were drawn from a non-random purposeful sample of stakeholders, targeting individuals in ministries and non-governmental organizations whose policy decisions and actions are likely to have an impact on the status of malaria. Summary statistics across the three countries are presented in aggregate. Important findings aggregated across countries included a belief that donor preferences and agendas were exerting too much influence on malaria policies in the countries. Respondents on average also thought that some relevant objectives such as engaging members of parliament by the agency responsible for malaria control in a particular country were not being given enough consideration in malaria decision-making. Factors found to influence decisions regarding specific malaria control strategies included donor agendas, costs, effectiveness of interventions, health and environmental impacts, compliance and/acceptance, financial sustainability, and vector resistance to insecticides. Malaria control decision-makers in Kenya, Uganda and Tanzania take into account health and environmental impacts as well as cost implications of different intervention strategies. Further engagement of government legislators and other policy makers is needed in order to increase funding from domestic sources, reduce donor dependence, sustain interventions and consolidate current gains in malaria.

Methodology for fleet deployment decisions. Final report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Stremel, J.; Matousek, M.

1995-01-01

In today`s more competitive energy market, selecting investment and operating plans for a generating system, specific plants, and major plant components is becoming increasingly critical and complex. As utilities consider off-system sales, the key factor for fleet deployment decisions is no longer simply minimizing revenue requirements. Rather, system-level value dominates. This is a measure that can be difficult to determine in the context of traditional decision making methods. Selecting the best fleet deployment option requires the ability to account for multiple sources of value under uncertain conditions for multiple utility stakeholders. The object of this paper was to develope andmore » test an approach for assessing the system-wide value of alternative fleet deployment decisions. This was done, and the approach was tested at Consolidated Edison and at Central Illinois Public Service Company.« less

Choices, choices: the application of multi-criteria decision analysis to a food safety decision-making problem.

PubMed

Fazil, A; Rajic, A; Sanchez, J; McEwen, S

2008-11-01

In the food safety arena, the decision-making process can be especially difficult. Decision makers are often faced with social and fiscal pressures when attempting to identify an appropriate balance among several choices. Concurrently, policy and decision makers in microbial food safety are under increasing pressure to demonstrate that their policies and decisions are made using transparent and accountable processes. In this article, we present a multi-criteria decision analysis approach that can be used to address the problem of trying to select a food safety intervention while balancing various criteria. Criteria that are important when selecting an intervention were determined, as a result of an expert consultation, to include effectiveness, cost, weight of evidence, and practicality associated with the interventions. The multi-criteria decision analysis approach we present is able to consider these criteria and arrive at a ranking of interventions. It can also provide a clear justification for the ranking as well as demonstrate to stakeholders, through a scenario analysis approach, how to potentially converge toward common ground. While this article focuses on the problem of selecting food safety interventions, the range of applications in the food safety arena is truly diverse and can be a significant tool in assisting decisions that need to be coherent, transparent, and justifiable. Most importantly, it is a significant contributor when there is a need to strike a fine balance between various potentially competing alternatives and/or stakeholder groups.

A Hybrid-Cloud Science Data System Enabling Advanced Rapid Imaging & Analysis for Monitoring Hazards

NASA Astrophysics Data System (ADS)

Hua, H.; Owen, S. E.; Yun, S.; Lundgren, P.; Moore, A. W.; Fielding, E. J.; Radulescu, C.; Sacco, G.; Stough, T. M.; Mattmann, C. A.; Cervelli, P. F.; Poland, M. P.; Cruz, J.

2012-12-01

Volcanic eruptions, landslides, and levee failures are some examples of hazards that can be more accurately forecasted with sufficient monitoring of precursory ground deformation, such as the high-resolution measurements from GPS and InSAR. In addition, coherence and reflectivity change maps can be used to detect surface change due to lava flows, mudslides, tornadoes, floods, and other natural and man-made disasters. However, it is difficult for many volcano observatories and other monitoring agencies to process GPS and InSAR products in an automated scenario needed for continual monitoring of events. Additionally, numerous interoperability barriers exist in multi-sensor observation data access, preparation, and fusion to create actionable products. Combining high spatial resolution InSAR products with high temporal resolution GPS products--and automating this data preparation & processing across global-scale areas of interests--present an untapped science and monitoring opportunity. The global coverage offered by satellite-based SAR observations, and the rapidly expanding GPS networks, can provide orders of magnitude more data on these hazardous events if we have a data system that can efficiently and effectively analyze the voluminous raw data, and provide users the tools to access data from their regions of interest. Currently, combined GPS & InSAR time series are primarily generated for specific research applications, and are not implemented to run on large-scale continuous data sets and delivered to decision-making communities. We are developing an advanced service-oriented architecture for hazard monitoring leveraging NASA-funded algorithms and data management to enable both science and decision-making communities to monitor areas of interests via seamless data preparation, processing, and distribution. Our objectives: * Enable high-volume and low-latency automatic generation of NASA Solid Earth science data products (InSAR and GPS) to support hazards monitoring. * Facilitate NASA-USGS collaborations to share NASA InSAR and GPS data products, which are difficult to process in high-volume and low-latency, for decision-support. * Enable interoperable discovery, access, and sharing of NASA observations and derived actionable products, and between the observation and decision-making communities. * Enable their improved understanding through visualization, mining, and cross-agency sharing. Existing InSAR & GPS processing packages and other software are integrated for generating geodetic decision support monitoring products. We employ semantic and cloud-based data management and processing techniques for handling large data volumes, reducing end product latency, codifying data system information with semantics, and deploying interoperable services for actionable products to decision-making communities.

Prognosis after treatment with multiple dental implants under general anesthesia and sedation in a cerebral palsy patient with mental retardation: A case report.

PubMed

Hong, Young-Joon; Dan, Jung-Bae; Kim, Myung-Jin; Kim, Hyun Jeong; Seo, Kwang-Suk

2017-06-01

Cerebral palsy is a non-progressive disorder resulting from central nervous system damage caused by multiple factors. Almost all cerebral palsy patients have a movement disorder that makes dental treatment difficult. Oral hygiene management is difficult and the risks for periodontitis, dental caries and loss of multiple teeth are high. Placement of dental implants for multiple missing teeth in cerebral palsy patients needs multiple rounds of general anesthesia, and the prognosis is poor despite the expense. Therefore, making the decision to perform multiple dental implant treatments on cerebral palsy patients is difficult. A 33-year-old female patient with cerebral palsy and mental retardation was scheduled for multiple implant treatments. She underwent computed tomography (CT) under sedation and the operation of nine dental implants under general anesthesia. Implant-supported fixed prosthesis treatment was completed. During follow-up, she had the anterior incisors extracted and underwent the surgery of 3 additional dental implants, completing the prosthetic treatment. Although oral parafunctions existed due to cerebral palsy, no implant failure was observed 9 years after the first implant surgery.

Less is more: The availability heuristic in early childhood.

PubMed

Geurten, Marie; Willems, Sylvie; Germain, Sophie; Meulemans, Thierry

2015-11-01

This study examined whether young children are influenced by the subjective experience associated with an easy or difficult recall when making memory decisions. Seventy-one children, aged 4, 6, and 8 years, were asked to generate either a small (easy condition) or large (hard condition) number of first names. Statistical analyses revealed that participants in the hard condition were more likely to infer that they did not know many names than participants in the easy condition, contrary to what would be expected if children based their memory judgement on the objective number of recalled items. Overall, our results support the hypothesis that children as young as 4 years old rely on the subjective experience of ease to regulate their decision-making processes. Theoretical implications of these findings are discussed. © 2015 The British Psychological Society.

Evaluating neural networks and artificial intelligence systems

NASA Astrophysics Data System (ADS)

Alberts, David S.

1994-02-01

Systems have no intrinsic value in and of themselves, but rather derive value from the contributions they make to the missions, decisions, and tasks they are intended to support. The estimation of the cost-effectiveness of systems is a prerequisite for rational planning, budgeting, and investment documents. Neural network and expert system applications, although similar in their incorporation of a significant amount of decision-making capability, differ from each other in ways that affect the manner in which they can be evaluated. Both these types of systems are, by definition, evolutionary systems, which also impacts their evaluation. This paper discusses key aspects of neural network and expert system applications and their impact on the evaluation process. A practical approach or methodology for evaluating a certain class of expert systems that are particularly difficult to measure using traditional evaluation approaches is presented.

Assessing Generalisability in Model-Based Economic Evaluation Studies: A Structured Review in Osteoporosis

PubMed Central

Urdahl, Hege; Manca, Andrea; Sculpher, Mark J

2008-01-01

Background To support decision making many countries have now introduced some formal assessment process to evaluate whether health technologies represent good ‘value for money’. These often take the form of decision models which can be used to explore elements of importance to generalisability of study results across clinical settings and jurisdictions. The objectives of the present review were to assess: (i) whether the published studies clearly defined the decision-making audience for the model; (ii) the transparency of the reporting in terms of study question, structure and data inputs; (iii) the relevance of the data inputs used in the model to the stated decision-maker or jurisdiction; and (iv) how fully the robustness of the model's results to variation in data inputs between locations was assessed. Methods Articles reporting decision-analytic models in the area of osteoporosis were assessed to establish the extent to which the information provided enabled decision makers in different countries/jurisdictions to fully appreciate the variability of results according to location, and the relevance to their own. Results Of the 18 articles included in the review, only three explicitly stated the decision-making audience. It was not possible to infer a decision-making audience in eight studies. Target population was well reported, as was resource and cost data, and clinical data used for estimates of relative risk reduction. However, baseline risk was rarely adapted to the relevant jurisdiction, and when no decision-maker was explicit it was difficult to assess whether the reported cost and resource use data was in fact relevant. A few studies used sensitivity analysis to explore elements of generalisability, such as compliance rates and baseline fracture risk rates, although such analyses were generally restricted to evaluating parameter uncertainty. Conclusion This review found that variability in cost-effectiveness across locations is addressed to a varying extent in modelling studies in the field of osteoporosis, limiting their use for decision-makers across different locations. Transparency of reporting is expected to increase as methodology develops, and decision-makers publish “reference case” type guidance. PMID:17129074

Decision-making around moving on from full-time education: the roles and experiences of parents of disabled young people with degenerative conditions.

PubMed

Maddison, Jane; Beresford, Bryony

2012-09-01

Little is known about the decision-making processes that take place within families when a disabled young person is moving on from full-time education and, particularly, parents' roles and experiences. This paper reports the analysis of data collected from a subsample of parents (representing seventeen families) participating in the Choice and Change Project who had discussed choices associated with their child leaving full-time education. (The Choice and Change Project is a longitudinal, qualitative study of choice-making by four different groups of service users including disabled young people with degenerative conditions and their parents.) The data were collected from parents during up to three semi-structured interviews conducted over a thirty-month period. Descriptive theories of decision-making informed the analysis. Parents differed in the extent to which they were actively involved in making choices about the 'destination' of their child after leaving full-time education. To some extent, the ability of the young person to make choices themselves influenced this. Parents who were assuming responsibility for making choices stressed the importance of having relevant information and felt professionals had a key role to play in supporting access to information. Parents used a number of criteria to guide their choice-making, including distance from home, perceived quality of the environment and staff and the young person's responses to the setting. Much of the information needed to make a choice required a visit to all the possible options. Ensuring such visits were positive and useful experiences for themselves and their child could be very difficult; support to achieve these visits was highly valued but not routinely provided. The study also highlights the lack of recognition given to the significant amount of work that many parents undertake to ensure that a choice is realised, and also to the emotional journey parents take when making or assisting in such decisions. © 2012 Blackwell Publishing Ltd.

Decision making and sequential sampling from memory

PubMed Central

Shadlen, Michael N.; Shohamy, Daphna

2016-01-01

Decisions take time, and as a rule more difficult decisions take more time. But this only raises the question of what consumes the time. For decisions informed by a sequence of samples of evidence, the answer is straightforward: more samples are available with more time. Indeed the speed and accuracy of such decisions are explained by the accumulation of evidence to a threshold or bound. However, the same framework seems to apply to decisions that are not obviously informed by sequences of evidence samples. Here we proffer the hypothesis that the sequential character of such tasks involves retrieval of evidence from memory. We explore this hypothesis by focusing on value-based decisions and argue that mnemonic processes can account for regularities in choice and decision time. We speculate on the neural mechanisms that link sampling of evidence from memory to circuits that represent the accumulated evidence bearing on a choice. We propose that memory processes may contribute to a wider class of decisions that conform to the regularities of choice-reaction time predicted by the sequential sampling framework. PMID:27253447

The Role of Time-Limited Trials in Dialysis Decision Making in Critically Ill Patients.

PubMed

Scherer, Jennifer S; Holley, Jean L

2016-02-05

Technologic advances, such as continuous RRT, provide lifesaving therapy for many patients. AKI in the critically ill patient, a fatal diagnosis in the past, is now often a survivable condition. Dialysis decision making for the critically ill patient with AKI is complex. What was once a question solely of survival now is nuanced by an individual's definition of quality of life, personal values, and short- and long-term prognoses. Clinical evaluation of AKI in the critically ill is multifaceted. Treatment decision making requires consideration of the natural evolution of the patient's AKI within the context of the global prognosis. Situations are often marked by prognostic uncertainty and clinical unknowns. In the face of these uncertainties, establishment of patient-directed therapies is imperative. A time-limited trial of continuous RRT in this setting is often appropriate but difficult to execute. Using patient preferences as a clinical guide, a proper time-limited trial requires assessment of prognosis, elicitation of patient values, strong communication skills, clear documentation, and often, appropriate integration of palliative care services. A well conducted time-limited trial can avoid interprofessional conflict and provide support for the patient, family, and staff. Copyright © 2016 by the American Society of Nephrology.

The history of ethical decision making in neonatal intensive care.

PubMed

Placencia, Frank X; McCullough, Laurence B

2011-01-01

Neonatal ethics has focused on 2 questions: is withholding potentially live-saving treatment from neonates ethically justified? and if so, who has the authority to decide? This article details how these questions developed and provides a description of the possible answers. In the first section, we review a selection of seminal articles by noted authors in the fields of ethics, medicine, and law. The second section provides a detailed account of the development of the Baby Doe Regulations and the impact they had on neonatal ethics, with particular attention to the emergence of the Best Interest Standard as a guideline for decision making. In the last section, we review the landmark position statements by the American Academy of Pediatric (AAP), and the focus on evidence-based decision making. We conclude that forgoing life-saving treatment is ethically justified. However, this requires a rigorous evidence-based process and is limited by the Best Interest Standard. The second question is more difficult to answer, but we feel that in light of legal limitations, physicians acting as both the infant advocate and a proxy for the state, decide what falls in the range of acceptable treatment options, with the parents free to choose within that range.

How we developed and piloted an electronic key features examination for the internal medicine clerkship based on a US national curriculum.

PubMed

Bronander, Kirk A; Lang, Valerie J; Nixon, L James; Harrell, Heather E; Kovach, Regina; Hingle, Susan; Berman, Norman

2015-01-01

Key features examinations (KFEs) have been used to assess clinical decision making in medical education, yet there are no reports of an online KFE-based on a national curriculum for the internal medicine clerkship. What we did: The authors developed and pilot tested an electronic KFE based on the US Clerkship Directors in Internal Medicine core curriculum. Teams, with expert oversight and peer review, developed key features (KFs) and cases. The exam was pilot tested at eight medical schools with 162 third and fourth year medical students, of whom 96 (59.3%) responded to a survey. While most students reported that the exam was more difficult than a multiple choice question exam, 61 (83.3%) students agreed that it reflected problems seen in clinical practice and 51 (69.9%) students reported that it more accurately assessed the ability to make clinical decisions. The development of an electronic KFs exam is a time-intensive process. A team approach offers built-in peer review and accountability. Students, although not familiar with this format in the US, recognized it as authentically assessing clinical decision-making for problems commonly seen in the clerkship.

[Refusal of care in the intensive care: how makes decision?].

PubMed

Borel, M; Veber, B; Villette-Baron, K; Hariri, S; Dureuil, B; Hervé, C

2009-11-01

Decision-making bringing to an admission or not in intensive care is complex. The aim of this study is to analyze with an ethical point of view the making decision process leading to the refusal and its consequences. It is proposed a setting in prospect through the principles of beneficence, non-maleficience, respect for autonomy, justice, and the Leonetti law. Prospective study in surgical reanimation at the University Hospital of Rouen over 9 months (November 2007-September 2008). Systematic collection for each non-admitted patient of the general characters, the methods of decision making, immediate becoming and within 48 h Constitution of two groups: patients for whom an admission in intensive care could be an unreasonable situation of obstinacy, and patients for whom an admission in reanimation would not be about unreasonable if it occurred. One hundred and fifty situations were analyzed. The potentially unreasonable character of an admission does not involve necessarily a refusal of care in intensive care. The question of the lack of place and equity in the access to the care is real but relative according to the typology of the patients. The research of the respect of the autonomy of the patient is difficult but could be facilitated. The Leonetti law does not appear to be able to be a framework with the situation of refusal of care in intensive care. It is not a question of going towards a systematic admission in intensive care of any patient proposed, but to make sure that so if there is a refusal, it is carried out according to a step ethically acceptable.

Improving the food waste composting facilities site selection for sustainable development using a hybrid modified MADM model.

PubMed

Liu, Kung-Ming; Lin, Sheng-Hau; Hsieh, Jing-Chzi; Tzeng, Gwo-Hshiung

2018-05-01

With the growth of population and the development of urbanization, waste management has always been a critical global issue. Recently, more and more countries have found that food waste constitutes the majority of municipal waste, if they are disposed of properly, will bring more benefits in sustainable development. Regarding the issue of selecting and improving the location to make the disposal facility towards achieving the aspiration level for sustainable development, since it involves multiple and complicated interaction factors about environment, society, and economy which have to be considered properly in the decision-making process of mutual influence relationship. It is basically a multiple attribute decision making (MADM) issue, a difficult problem which has been obsessing the governments of many countries is widely studied and discussed. This study uses the new hybrid modified MADM model, as follows, first to build an influential network relation map (INRM) via DEMATEL technique, next to confirm the influential weightings via DANP (DEMATEL-based ANP), and then to construct a decision-making model via a hybrid modified VIKOR method to improve and select the location for remaining the best disposal facilities. Finally, an empirical case study is illustrated to demonstrate that the proposed model can be effective and useful. In finding the process of decision making, environmental pollution is the main concern of many people in the area, but actually it is the resistance by the general public that has to be considered with first priority. Copyright © 2018. Published by Elsevier Ltd.

Watchful waiting or induction of labour--a matter of informed choice: identification, analysis and critical appraisal of decision aids and patient information regarding care options for women with uncomplicated singleton late and post term pregnancies: a review.

PubMed

Berger, Bettina; Schwarz, Christiane; Heusser, Peter

2015-05-07

Decision-making during pregnancy regarding different options of care can be difficult, particularly when risks of intervention versus no intervention for mother and baby are unclear. Unbiased information and support for decision making may be beneficial in these situations. The management of normal pregnancies at and beyond term is an example of such a situation. In order to determine the need to develop an evidence-based decision aid this paper searches, analyses and appraises patient decision aids and patient information leaflets regarding care options in cases of late term and post-term pregnancies, including complementary and alternative medicine (CAM). A literature search was carried out in a variety of lay and medical databases. written information related to uncomplicated singleton pregnancies and targeted at lay people. Analysis and appraisal of included material by means of quality criteria was set up based on the International Patient Decision Aid Standards accounting for evidence-basing of CAM options. Inclusion of two decision aids and eleven leaflets from four decision aids and sixteen leaflets. One decision aid met the quality criteria almost completely, the other one only insufficiently despite providing some helpful information. Only one leaflet is of good quality, but cannot substitute a decision aid. There is an urgent need for the design of an evidence-based decision aid of good quality for late-term or post-term pregnancy, particularly in German language.

Shared decision making in the safety net: where do we go from here?

PubMed

Bouma, Angelique B; Tiedje, Kristina; Poplau, Sara; Boehm, Deborah H; Shah, Nilay D; Commers, Matthew J; Linzer, Mark; Montori, Victor M

2014-01-01

Shared decision making (SDM) is an interactive process between clinicians and patients in which both share information, deliberate together, and make clinical decisions. Clinics serving safety net patients face special challenges, including fewer resources and more challenging work environments. The use of SDM within safety net institutions has not been well studied. We recruited a convenience sample of 15 safety net primary care clinicians (13 physicians, 2 nurse practitioners). Each answered a 9-item SDM questionnaire and participated in a semistructured interview. From the transcribed interviews and questionnaire data, we identified themes and suggestions for introducing SDM into a safety net environment. Clinicians reported only partially fulfilling the central components of SDM (sharing information, deliberating, and decision making). Most clinicians expressed interest in SDM by stating that they "selected a treatment option together" with patients (8 of 15 in strong or complete agreement), but only a minority (3 of 15) "thoroughly weighed the different treatment options" together with patients. Clinicians attributed this gap to many barriers, including time pressure, overwhelming visit content, patient preferences, and lack of available resources. All clinicians believed that lack of time made it difficult to practice SDM. To increase use of SDM in the safety net, efficient SDM interventions designed for this environment, team care, and patient engagement in SDM will need further development. Future studies should focus on adapting SDM to safety net settings and determine whether SDM can reduce health care disparities.

Professional responsibility and decision-making in the context of a disease-focused model of nursing care: The difficulties experienced by Spanish nurses.

PubMed

Rodrigo, Olga; Caïs, Jordi; Monforte-Royo, Cristina

2017-10-01

When, in 1977, nurse education in Spain was transferred to universities a more patient-centred, the Anglo-American philosophy of care was introduced into a context in which nurses had traditionally prioritised their technical skills. This paper examines the characteristics of the nurse's professional role in Spain, where the model of nursing practice has historically placed them in a position akin to that of physician assistants. The study design was qualitative and used the method of analytic induction. Participants were selected by means of theoretical sampling and then underwent in-depth interviews. The resulting material was analysed using an approach based on the principles of grounded theory. Strategies were applied to ensure the credibility, transferability, dependability and confirmability of the findings. The main conclusion is that nurses in Spain continue to work within a disease-focused model of care, making it difficult for them to take responsibility for decision-making. © 2017 John Wiley & Sons Ltd.

Assessing the usefulness and acceptability of a low health literacy online decision aid about reproductive choices for younger women with breast cancer: the aLLIAnCE pilot study protocol.

PubMed

Peate, Michelle; Smith, Sian Karen; Pye, Victoria; Hucker, Alice; Stern, Catharyn; Stafford, Lesley; Oakman, Catherine; Chin-Lenn, Laura; Shanahan, Kerry; Ratnayake Gamage, Nipuni; Hickey, Martha

2017-01-01

Young women diagnosed with breast cancer may be confronted by many difficult decisions, especially around fertility preservation prior to commencing cancer treatment. The information to be conveyed is complex, and it may be difficult to weigh up the risks and benefits of the different fertility preservation options available. This complexity is compounded by the widespread low levels of literacy and health literacy in Australia, which may result in greater difficulties in understanding available health information and in decision-making. A working group of experts have developed a fertility-related online decision aid for a low health literacy population, guided by health literacy principles. The decision aid will be pilot tested with 30 women diagnosed with early breast cancer between 5 years and 6 months previously. To be eligible, at the time of diagnosis, women must be between 18 and 40 years (inclusive), pre-menopausal, have no history of metastatic disease, have not completed their families, be able to give informed consent and have low health literacy. Participants will be asked to reflect back to the time in which they were diagnosed. Participants will complete a questionnaire before and after reviewing the decision aid to determine the feasibility, use and acceptability of the decision aid. The decision aid will be modified accordingly. Participants may also choose to review a previously developed (high literacy) decision aid and provide feedback in comparison to the low health literacy decision aid. This project represents the first study to develop an online fertility decision aid developed from low health literacy models in the context of breast cancer. It is anticipated that the low health literacy decision aid will be useful and acceptable to young women with low health literacy who have been diagnosed with breast cancer and that it will be preferred over the high literacy decision aid. ACTRN12615001364561p.

Competence, practical rationality and what a patient values.

PubMed

Craigie, Jillian

2011-07-01

According to the principle of patient autonomy, patients have the right to be self-determining in decisions about their own medical care, which includes the right to refuse treatment. However, a treatment refusal may legitimately be overridden in cases where the decision is judged to be incompetent. It has recently been proposed that in assessments of competence, attention should be paid to the evaluative judgments that guide patients' treatment decisions. In this paper I examine this claim in light of theories of practical rationality, focusing on the difficult case of an anorexic person who is judged to be competent and refuses treatment, thereby putting themselves at risk of serious harm. I argue that the standard criteria for competence assess whether a treatment decision satisfies the goals of practical decision-making, and that this same criterion can be applied to a patient's decision-guiding commitments. As a consequence I propose that a particular understanding of practical rationality offers a theoretical framework for justifying involuntary treatment in the anorexia case. © 2009 Blackwell Publishing Ltd.

Improving Professional Judgments of Risk and Amenability in Juvenile Justice

PubMed Central

Mulvey, Edward P.; Iselin, Anne-Marie R.

2013-01-01

Summary The dual requirement to ensure community safety and promote a youthful offender’s positive development permeates policy and frames daily practice in juvenile justice. Balancing those two demands, explain Edward Mulvey and Anne-Marie Iselin, requires justice system professionals at all levels to make extremely difficult decisions about the likely risk and amenability to treatment of adolescent offenders. Mulvey and Iselin point out that although various forms of “structured” decision-making instruments are used widely in other fields, juvenile justice professionals today make limited use of these tools. Instead, they make decisions based mainly on their intuition about whether the adolescent before them is more likely to harm the community or to use justice system services to turn his life around. The reluctance of busy court professionals to use these structured decision-making tools, they say, arises partly from their heavy work load. But it also grows out of the ethos of the juvenile court itself. Restricting an adolescent’s freedom or access to interventions based on a tallying of empirical data is antithetical to viewing each adolescent as a unique individual whose life chances may remain intact with developmentally appropriate intervention. Mulvey and Iselin recommend and examine three ways to integrate structured judgment approaches into the juvenile justice system that both capitalize on their strengths and support the court’s attempts to provide fair, individualized justice. First, more reliance on actuarial methods at detention and intake would promote more efficient and equitable screening of cases for subsequent court involvement. Second, the use of structured decision making by probation officers could provide more consistent and valid guidance for the court when formulating dispositions. Finally, implementing structured data systems to chart the progress of adolescents in placement could allow judges to oversee service providers more effectively. The challenge for the juvenile system, say the authors, will be to harness the new capacities of the science of decision making and of computer technology to increase the efficiency of its limited resources for the benefit both of the community and of the adolescents in the system. PMID:21337997

Does accountability for reasonableness work? A protocol for a mixed methods study using an audit tool to evaluate the decision-making of clinical commissioning groups in England.

PubMed

Kieslich, Katharina; Littlejohns, Peter

2015-07-10

Clinical commissioning groups (CCGs) in England are tasked with making difficult decisions on which healthcare services to provide against the background of limited budgets. The question is how to ensure that these decisions are fair and legitimate. Accounts of what constitutes fair and legitimate priority setting in healthcare include Daniels' and Sabin's accountability for reasonableness (A4R) and Clark's and Weale's framework for the identification of social values. This study combines these accounts and asks whether the decisions of those CCGs that adhere to elements of such accounts are perceived as fairer and more legitimate by key stakeholders. The study addresses the empirical gap arising from a lack of research on whether frameworks such as A4R hold what they promise. It aims to understand the criteria that feature in CCG decision-making. Finally, it examines the usefulness of a decision-making audit tool (DMAT) in identifying the process and content criteria that CCGs apply when making decisions. The adherence of a sample of CCGs to criteria emerging from theories of fair priority setting will be examined using the DMAT developed by PL. The results will be triangulated with data from semistructured interviews with key stakeholders in the CCG sample to ascertain whether there is a correlation between those CCGs that performed well in the DMAT exercise and those whose decisions are perceived positively by interviewees. Descriptive statistical methods will be used to analyse the DMAT data. A combination of quantitative and qualitative content analysis methods will be used to analyse the interview transcripts. Full ethics approval was received by the King's College London Biomedical Sciences, Dentistry, Medicine and Natural and Mathematical Sciences Research Ethics Subcommittee. The results of the study will be disseminated through publications in peer review journals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Managing healthcare budgets in times of austerity: the role of program budgeting and marginal analysis.

PubMed

Mitton, Craig; Dionne, Francois; Donaldson, Cam

2014-04-01

Given limited resources, priority setting or choice making will remain a reality at all levels of publicly funded healthcare across countries for many years to come. The pressures may well be even more acute as the impact of the economic crisis of 2008 continues to play out but, even as economies begin to turn around, resources within healthcare will be limited, thus some form of rationing will be required. Over the last few decades, research on healthcare priority setting has focused on methods of implementation as well as on the development of approaches related to fairness and legitimacy and on more technical aspects of decision making including the use of multi-criteria decision analysis. Recently, research has led to better understanding of evaluating priority setting activity including defining 'success' and articulating key elements for high performance. This body of research, however, often goes untapped by those charged with making challenging decisions and as such, in line with prevailing public sector incentives, decisions are often reliant on historical allocation patterns and/or political negotiation. These archaic and ineffective approaches not only lead to poor decisions in terms of value for money but further do not reflect basic ethical conditions that can lead to fairness in the decision-making process. The purpose of this paper is to outline a comprehensive approach to priority setting and resource allocation that has been used in different contexts across countries. This will provide decision makers with a single point of access for a basic understanding of relevant tools when faced with having to make difficult decisions about what healthcare services to fund and what not to fund. The paper also addresses several key issues related to priority setting including how health technology assessments can be used, how performance can be improved at a practical level, and what ongoing resource management practice should look like. In terms of future research, one of the most important areas of priority setting that needs further attention is how best to engage public members.