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Sanders S, Cheung WJ, Bakewell F, Landreville JM, Rangel C, D'Egidio G, Eagles D. How Emergency Medicine Residents Have Conversations About Life-Sustaining Treatments in Critical Illness: A Qualitative Study Using Inductive Thematic Analysis. Ann Emerg Med 2023; 82:583-593. [PMID: 37074255 DOI: 10.1016/j.annemergmed.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 04/20/2023]
Abstract
STUDY OBJECTIVE The inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness. METHODS Using qualitative methods, semistructured interviews were conducted with a purposive sample of emergency medicine residents in Canada from August to December 2021. Inductive thematic analysis of the interview transcripts was conducted using line-by-line coding, and key themes were identified through comparative analysis. Data collection continued until thematic saturation was reached. RESULTS Seventeen emergency medicine residents from 9 Canadian universities were interviewed. Two factors guided residents' treatment recommendations (a duty to provide a recommendation and the balance between disease prognosis and patient values). Three factors influenced residents' comfort when making recommendations (time constraints, uncertainty, and moral distress). CONCLUSION While conducting acute goals-of-care discussions with critically ill patients or their substitute decision makers in the emergency department, residents felt a sense of duty to provide a recommendation informed by an intersection between the patient's disease prognosis and the patient's values. Their comfort in making these recommendations was limited by time constraints, uncertainty, and moral distress. These factors are important for informing future educational strategies.
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Affiliation(s)
- Steven Sanders
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario.
| | - Warren J Cheung
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Francis Bakewell
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Cristian Rangel
- Department of Medicine, University of Ottawa, Ottawa, Ontario
| | - Gianni D'Egidio
- Department of Critical Care, University of Ottawa, Ottawa, Ontario
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario
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Smeele NVR, Chorus CG, Schermer MHN, de Bekker-Grob EW. Towards machine learning for moral choice analysis in health economics: A literature review and research agenda. Soc Sci Med 2023; 326:115910. [PMID: 37121066 DOI: 10.1016/j.socscimed.2023.115910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Discrete choice models (DCMs) for moral choice analysis will likely lead to erroneous model outcomes and misguided policy recommendations, as only some characteristics of moral decision-making are considered. Machine learning (ML) is recently gaining interest in the field of discrete choice modelling. This paper explores the potential of combining DCMs and ML to study moral decision-making more accurately and better inform policy decisions in healthcare. METHODS An interdisciplinary literature search across four databases - PubMed, Scopus, Web of Science, and Arxiv - was conducted to gather papers. Based on the Preferred Reporting Items for Systematic and Meta-analyses (PRISMA) guideline, studies were screened for eligibility on inclusion criteria and extracted attributes from eligible papers. Of the 6285 articles, we included 277 studies. RESULTS DCMs have shortcomings in studying moral decision-making. Whilst the DCMs' mathematical elegance and behavioural appeal hold clear interpretations, the models do not account for the 'moral' cost and benefit in an individual's utility calculation. The literature showed that ML obtains higher predictive power, model flexibility, and ability to handle large and unstructured datasets. Combining the strengths of ML methods with DCMs has the potential for studying moral decision-making. CONCLUSIONS By providing a research agenda, this paper highlights that ML has clear potential to i) find and deepen the utility specification of DCMs, and ii) enrich the insights extracted from DCMs by considering the intrapersonal determinants of moral decision-making.
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Affiliation(s)
- Nicholas V R Smeele
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, the Netherlands.
| | - Caspar G Chorus
- Department of Engineering Systems and Services, Delft University of Technology, Delft, the Netherlands; Faculty of Industrial Design Engineering, Delft University of Technology, Delft, the Netherlands
| | - Maartje H N Schermer
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther W de Bekker-Grob
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Choice Modelling Centre, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam, Erasmus University Rotterdam, Rotterdam, the Netherlands
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3
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Ethical issues and dilemmas in spinal cord injury rehabilitation in the developing world: a mixed-method study. Spinal Cord 2022; 60:882-887. [PMID: 35523952 DOI: 10.1038/s41393-022-00808-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Mixed-method study (small group discussions and online literature search). OBJECTIVES Identify the ethical issues and dilemmas faced by rehabilitation professionals involved in the service delivery to the persons with spinal cord injury (SCI) in the low income and lower-middle-income countries (LIC/LMIC) located in Asia. SETTING Small group discussions in three biomedical conferences in Dhaka, Bangladesh and Kualalampur, Malaysia. METHODS Three small group discussions (30-45 min each) were held during three international conferences in 2019. The conferences brought together experts in the fields of neurology, rehabilitation, neurorehabilitation, and bioethics. A summary of SCI practice points and dilemmas were documented including goals of care, duties of rehabilitation professionals, health care worker-patient relationships, roles, and expectations of family members at different care settings. RESULTS There is a paucity of literature on this topic. The application of the principles of contemporary bioethics in the pluralistic societies of LIC/LMIC can be challenging. The ethical dilemmas faced by rehabilitation professionals working in LIC/LMIC are diverse and different from those reported from the Western and developed countries. Ethical issues and dilemmas identified were understanding patient autonomy in decision making, lack of insurance for SCI rehabilitation, financial challenges, challenges of providing emerging technology in SCI rehabilitation and SCI rehabilitation during disasters. CONCLUSIONS We have summarized the possible ethical issues and dilemmas which rehabilitation professionals in LIC/LMIC may encounter during delivery of SCI rehabilitation services. We hope it generates a discussion on an often-neglected aspect of SCI care in the LIC/LMIC and helps identify the complexities of ethical dilemmas unique to persons with SCI living in a developing country.
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Liang Z, Xu M, Liu G, Zhou Y, Howard P. Patient-centred care and patient autonomy: doctors' views in Chinese hospitals. BMC Med Ethics 2022; 23:38. [PMID: 35395761 PMCID: PMC8994393 DOI: 10.1186/s12910-022-00777-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 03/29/2022] [Indexed: 11/29/2022] Open
Abstract
Background Patient-centred care and patient autonomy is one of the key factors to better quality of service provision, hence patient outcomes. It enables the development of patients’ trusts which is an important element to a better doctor-patient relationship. Given the increasing number of patient disputes and conflicts between patients and doctors in Chinese public hospital, it is timely to ensure patient-centred care is fully and successfully implemented. However, limited studies have examined the views and practice in different aspects of patient-centred care among doctors in the Chinese public hospitals. Methods A quantitative approach was adopted by distributing paper-based questionnaires to doctors and patients in two hospitals (Level III and Level II) in Jinan, Shandong province, China. Results In total, 614 doctors from the surgical and internal medicine units of the two hospitals participated in the survey yielding 90% response rates. The study confirmed the inconsistent views among doctors in terms of their perception and practice in various aspects patient-centred care and patient autonomy regardless of the hospital where they work (category II or category III), their unit speciality (surgical or non-surgical), their gender or seniority. The high proportion of doctors (more than 20%) who did not perceive the importance of patient consultation prior to determining diagnostic and treatment procedure is alarming. This in in part due to the belief held by more than half of the doctors that patients were unable to make rational decisions and their involvement in treatment planning process did not necessarily lead to better treatment outcomes. Conclusion The study calls for the development of system level policy and organisation wide strategies in encouraging and enabling the practice of patient-centred care and patient autonomy with the purposes of improving the quality of the service provided to patients by Chinese hospitals. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00777-w.
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Affiliation(s)
- Zhanming Liang
- The Second Affiliated Hospital of Shandong First Medical University, Taian, China.,James Cook University, Townsville, Australia
| | - Min Xu
- The Second Affiliated Hospital of Shandong First Medical University, Taian, China.
| | - Guowei Liu
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yongli Zhou
- Shandong University of Traditional Chinese Medicine, Jinan, China
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Finocchiaro G, Magavern EF, Georgioupoulos G, Maurizi N, Sinagra G, Carr-White G, Pantazis A, Olivotto I. Sudden cardiac death in cardiomyopathies: acting upon "acceptable" risk in the personalized medicine era. Heart Fail Rev 2022; 27:1749-1759. [PMID: 35083629 DOI: 10.1007/s10741-021-10198-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 11/04/2022]
Abstract
Patients with cardiomyopathies are confronted with the risk of sudden cardiac death (SCD) throughout their lifetime. Despite the fact that SCD is relatively rare, prognostic stratification is an integral part of physician-patient discussion, with the goal of risk modification and prevention. The current approach is based on a concept of "acceptable risk." However, there are intrinsic problems with an algorithm-based approach to risk management, magnified by the absence of robust evidence underlying clinical decision support tools, which can make high- versus low-risk classifications arbitrary. Strategies aimed at risk reduction range from selecting patients for an implantable cardioverter defibrillator (ICD) to disqualification from competitive sports. These clinical options, especially when implying the use of finite financial resources, are often delivered from the physician's perspective citing decision-making algorithms. When the burden of intervention-related risks or financial costs is deemed higher than an "acceptable risk" of SCD, the patient's perspective may not be appropriately considered. Designating a numeric threshold of "acceptable risk" has ethical implications. One could reasonably ask "acceptable to whom?" In an era when individual choice and autonomy are pillars of the physician-patient relationship, the subjective aspects of perceived risk should be acknowledged and be part of shared decision-making. This is particularly true when the lack of a strong scientific evidence base makes a dichotomous algorithm-driven approach suboptimal for unmitigated translation to clinical practice.
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Affiliation(s)
- Gherardo Finocchiaro
- Cardiothoracic Centre, Guy's and St Thomas' Hospital, London, UK. .,King's College London, London, UK. .,Royal Brompton Hospital, Sydney St, London, SW3 6NP, UK. .,Cardiovascular Clinical Academic Group, St George's, University of London, London, UK.
| | - Emma F Magavern
- The London School of Medicine and Dentistry, William Harvey Research Institute, Barts, London, UK.,Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | | | - Niccolo' Maurizi
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Gerald Carr-White
- Cardiothoracic Centre, Guy's and St Thomas' Hospital, London, UK.,King's College London, London, UK
| | | | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
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Lamb CC, Wang Y. PHYSICIAN CHARACTERISTICS THAT INFLUENCE PATIENT PARTICIPATION IN THE TREATMENT OF PRIMARY IMMUNODEFICIENCY. PATIENT EDUCATION AND COUNSELING 2020; 103:2280-2289. [PMID: 32475713 DOI: 10.1016/j.pec.2020.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Shared decision making (SDM) is recommended to improve healthcare quality. Physicians who use a rational decision-making style and patient-centric approach are more likely to incorporate SDM into clinical practice. This paper explores how certain physician characteristics such as gender, age, race, experience, and specialty explain patient participation. METHODS A multi-group structural equation model tested the relationship between physician decision-making styles, patient-centered care, physician characteristics, and patient participation in clinical treatment decisions. A survey was completed by 330 physicians who treat primary immunodeficiency. Sample group responses were compared between groups across specialty, age, race, experience, or gender. RESULTS A patient-centric approach was the main factor that encouraged SDM independent of physician decision-making style with both treatment protocols and product choices. The positive effect of patient-centrism is stronger for immunologists, more experienced physicians, or male physicians. A rational decision-making style increases participation for non-immunologists, older physicians, white physicians, less-experienced physicians and female physicians. CONCLUSION A patient-centric approach, rational decision-making and certain physician characteristics help explain patient participation in clinical decisions. Practice Implications Future SDM research and policy initiatives should focus on physician adoption of patient-centric approaches to chronic care diseases and the potential bias associated with physician characteristics and decision-making style.
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Affiliation(s)
- Christopher C Lamb
- BioSolutions Services, Englewood Cliffs, New Jersey, United States; Department of Management and Entrepreneurship, Silberman College of Business, Fairleigh Dickinson University, Teaneck, New Jersey, United States; Weatherhead School of Management, Case Western Reserve University, Cleveland, Ohio, USA.
| | - Yunmei Wang
- Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine and Harrington Heart &Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio 44106, USA
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Morley J, Floridi L. The Limits of Empowerment: How to Reframe the Role of mHealth Tools in the Healthcare Ecosystem. SCIENCE AND ENGINEERING ETHICS 2020; 26:1159-1183. [PMID: 31172424 PMCID: PMC7286867 DOI: 10.1007/s11948-019-00115-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/28/2019] [Indexed: 05/03/2023]
Abstract
This article highlights the limitations of the tendency to frame health- and wellbeing-related digital tools (mHealth technologies) as empowering devices, especially as they play an increasingly important role in the National Health Service (NHS) in the UK. It argues that mHealth technologies should instead be framed as digital companions. This shift from empowerment to companionship is advocated by showing the conceptual, ethical, and methodological issues challenging the narrative of empowerment, and by arguing that such challenges, as well as the risk of medical paternalism, can be overcome by focusing on the potential for mHealth tools to mediate the relationship between recipients of clinical advice and givers of clinical advice, in ways that allow for contextual flexibility in the balance between patiency and agency. The article concludes by stressing that reframing the narrative cannot be the only means for avoiding harm caused to the NHS as a healthcare system by the introduction of mHealth tools. Future discussion will be needed on the overarching role of responsible design.
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Affiliation(s)
- Jessica Morley
- Oxford Internet Institute, University of Oxford, 1 St Giles, Oxford, OX1 3JS, UK.
| | - Luciano Floridi
- Oxford Internet Institute, University of Oxford, 1 St Giles, Oxford, OX1 3JS, UK
- The Alan Turing Institute, 96 Euston Road, London, NW1 2DB, UK
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8
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Altman MR, Oseguera T, McLemore MR, Kantrowitz-Gordon I, Franck LS, Lyndon A. Information and power: Women of color's experiences interacting with health care providers in pregnancy and birth. Soc Sci Med 2019; 238:112491. [DOI: 10.1016/j.socscimed.2019.112491] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 06/25/2019] [Accepted: 08/11/2019] [Indexed: 02/02/2023]
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9
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Hensley MK. A Tale of Two Lungs. JAMA 2019; 322:613-614. [PMID: 31429900 DOI: 10.1001/jama.2019.11287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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10
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Shah R, Hagell A. Public health for paediatricians:How can behavioural economics help to make paediatric practice more effective? Arch Dis Child Educ Pract Ed 2019; 104:146-149. [PMID: 30219756 DOI: 10.1136/archdischild-2018-315229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/18/2018] [Indexed: 11/04/2022]
Abstract
Understanding the principles of behavioural economics is important for paediatricians because behavioural economics offers ideas to help improve the quality of paediatric care. It can also be used to inform health interventions/policy at a population level. This paper summarises key behavioural economic concepts such as bounded rationality, bounded willpower and social influence, explaining how they can be used to shape healthy behaviours in children and adolescents. Case studies of interventions that have used behavioural economics principles (sometimes called 'nudge theory') are provided.
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Affiliation(s)
- Rakhee Shah
- Association for Young People's Health, London, UK
| | - Ann Hagell
- Association for Young People's Health, London, UK
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Hogikyan ND, Shuman AG. Can the Doctor Still Know Better? Reflections upon Professionalism and Duty. Otolaryngol Head Neck Surg 2019; 160:616-618. [DOI: 10.1177/0194599819831254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Norman D. Hogikyan
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Andrew G. Shuman
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Bailoor K, Valley T, Perumalswami C, Shuman AG, DeVries R, Zahuranec DB. How acceptable is paternalism? A survey-based study of clinician and nonclinician opinions on paternalistic decision making. AJOB Empir Bioeth 2018; 9:91-98. [PMID: 29630457 DOI: 10.1080/23294515.2018.1462273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We conducted an empirical study to explore clinician and lay opinions on the acceptability of physician paternalism. Respondents read a vignette describing a patient with brain hemorrhage facing urgent surgery that would be lifesaving but would result in long-term severe disability. Cases were randomized to show either low or high surrogate distress and certain or uncertain prognosis, with respondents rating the acceptability of not offering brain surgery. Clinicians (N = 169) were more likely than nonclinicians (N = 649) to find the doctor withholding surgery acceptable (30.2% vs. 11.4%, p ≤ 0.001). Among clinicians, the doctor withholding surgery was more acceptable when prognosis was certain to be poor (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.04, 4.01). There was no effect of surrogate distress on clinician ratings. Responses among lay public were more variable. Given the differences in attitudes across clinicians and lay public, there is an ongoing need to engage stakeholders in the process of end-of-life decision making.
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Affiliation(s)
| | - Thomas Valley
- b Department of Internal Medicine , Michigan Medicine
| | | | - Andrew G Shuman
- c Center for Bioethics and Social Sciences in Medicine, Michigan Medicine.,d Department of Otolaryngology , Michigan Medicine
| | - Raymond DeVries
- c Center for Bioethics and Social Sciences in Medicine, Michigan Medicine.,e Department of Learning Health Sciences , Michigan Medicine.,f Department of Obstetrics and Gynecology , Michigan Medicine
| | - Darin B Zahuranec
- c Center for Bioethics and Social Sciences in Medicine, Michigan Medicine.,g Department of Neurology , Michigan Medicine
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Copnell G. Informed consent in physiotherapy practice: it is not what is said but how it is said. Physiotherapy 2018; 104:67-71. [PMID: 29352579 DOI: 10.1016/j.physio.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
Abstract
This paper discusses the concept of informed consent in the context of contemporary biomedical ethics. A change in UK law regarding what information should be provided to patients has brought to the fore the role of physiotherapists in the process of gaining informed consent. It is important that physiotherapists are aware of how this change in the law will affect their practice. For an individual to consent, they need to have both the capacity and freedom to exercise rational thought. These concepts are challenged in contemporary biomedical ethics. An individual's ability to make rational decisions has been increasingly questioned by empirical evidence from behavioural psychology. In addition, the concept of freedom in contemporary neoliberal societies has also been critically examined. Liberal paternalism has been advocated by some as a means of helping patients to make better decisions about their care. Actualised as a 'nudge', liberal paternalism has been influential in a number of health policies, and has recently been discussed as a means of gaining consent from patients for assessments and treatments. Physiotherapists engage directly with patients and, through this engagement, construct a therapeutic environment that aims to build mutual trust. This paper questions the legitimacy of informed consent, and presents the argument that, through communicative actions, physiotherapists nudge patients into consenting to assessments and treatments.
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Affiliation(s)
- G Copnell
- University of East London, Romford Rd, Stratford, London E15 4LZ, UK.
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Zhang Z, Bickmore TW, Paasche-Orlow MK. Perceived organizational affiliation and its effects on patient trust: Role modeling with embodied conversational agents. PATIENT EDUCATION AND COUNSELING 2017; 100:1730-1737. [PMID: 28381330 DOI: 10.1016/j.pec.2017.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 03/08/2017] [Accepted: 03/09/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Verbal and non-verbal behaviors, which are known as "relational contextualization cues", relay information about relationships and how they are structured. We developed a computer-simulated provider conducting an informed consent process for clinical research to investigate the effects of a provider's alignment of interests with a patient, the research team, or a neutral party on patient trust in the provider. METHODS Participants (N=43) interacted with a simulated provider for a research informed consent process in a three-arm, counterbalanced, within-subjects experiment. Participants reported their trust in the simulated provider after each treatment. RESULTS Participants successfully recognized the alignment manipulation, and perceived the patient-aligned provider as more trustworthy than the other providers. Participants were also more satisfied with the patient-aligned provider, liked this provider more, expressed more desire to continue working with this provider, and stated that they were significantly more likely to sign the consent form after interacting with this provider compared to the other two. CONCLUSION Relational contextualization that aligns with the patient increases trust, satisfaction, and willingness to enroll in the context of research informed consent. PRACTICE IMPLICATIONS Health providers should align themselves with patients' interests.
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Affiliation(s)
- Zhe Zhang
- College of Computer and Information Science, Northeastern University, Boston, MA, USA.
| | - Timothy W Bickmore
- College of Computer and Information Science, Northeastern University, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; Boston Medical Center, Boston, MA, USA
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Walker P, Lovat T. Dialogic Consensus In Clinical Decision-Making. JOURNAL OF BIOETHICAL INQUIRY 2016; 13:571-580. [PMID: 27535798 DOI: 10.1007/s11673-016-9743-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 05/18/2016] [Indexed: 06/06/2023]
Abstract
This paper is predicated on the understanding that clinical encounters between clinicians and patients should be seen primarily as inter-relations among persons and, as such, are necessarily moral encounters. It aims to relocate the discussion to be had in challenging medical decision-making situations, including, for example, as the end of life comes into view, onto a more robust moral philosophical footing than is currently commonplace. In our contemporary era, those making moral decisions must be cognizant of the existence of perspectives other than their own, and be attuned to the demands of inter-subjectivity. Applicable to clinical practice, we propose and justify a Habermasian approach as one useful means of achieving what can be described as dialogic consensus. The Habermasian approach builds around, first, his discourse theory of morality as universalizable to all and, second, communicative action as a cooperative search for truth. It is a concrete way to ground the discourse which must be held in complex medical decision-making situations, in its actual reality. Considerations about the theoretical underpinnings of the application of dialogic consensus to clinical practice, and potential difficulties, are explored.
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Affiliation(s)
- Paul Walker
- Clinical Unit in Ethics and Health Law, Faculty of Medicine and Health, University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Terry Lovat
- Philosophy, Religion & Theology, University of Newcastle, Callaghan, NSW, 2308, Australia
- University of Oxford, Oxford, UK
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16
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Perry J, Wöhlke S, Heßling AC, Schicktanz S. Why take part in personalised cancer research? Patients' genetic misconception, genetic responsibility and incomprehension of stratification-an empirical-ethical examination. Eur J Cancer Care (Engl) 2016; 26. [PMID: 27507437 DOI: 10.1111/ecc.12563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2016] [Indexed: 01/25/2023]
Abstract
Therapeutic misconception is a well-known challenge for informed decision-making for cancer research participants. What is still missing, is a detailed understanding of the impact of "personalised" treatment research (e.g. biomarkers for stratification) on research participants. For this, we conducted the first longitudinal empirical-ethical study based on semi-structured interviews with colorectal cancer patients (n = 40) enrolled in a biomarker trial for (neo)adjuvant treatment, analysing the patients' understanding of and perspectives on research and treatment with qualitative methods. In addition to therapeutic misconception based on patients' confusion of research and treatment, and here triggered by misled motivation, information paternalism or incomprehension, we identified genetic misconception and genetic responsibility as new problematic issues. Patients mainly were not aware of the major research aim of future stratification into responders and non-responders nor did they fully acknowledge this as the aim for personalised cancer research. Thus, ethical and practical reflection on informed decision-making in cancer treatment and research should take into account the complexity of lay interpretations of modern personalised medicine. Instead of very formalistic, liability-oriented informed consent procedures, we suggest a more personalised communication approach to inform and motivate patients for cancer research.
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Affiliation(s)
- J Perry
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - S Wöhlke
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - A C Heßling
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - S Schicktanz
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
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Walker P, Lovat T. Concepts of personhood and autonomy as they apply to end-of-life decisions in intensive care. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2015; 18:309-315. [PMID: 25304603 DOI: 10.1007/s11019-014-9604-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Amongst traditionally-available frameworks within which end-of-life decisions in Intensive Care Units (ICU) are situated, we favour Ordinary versus Extra-ordinary care distinctions as the most helpful. Predicated on this framework, we revisit the concepts of personhood and autonomy. We argue that a full account of personhood locates its foundation in relationships with others, rather than merely in "rationality". A full account of autonomy also recognises relationships with others, as well as the actual reality of the patient's situation-in-the-world. The fact that, when critically ill, the patient may no longer be able to take an active role in decision-making does not bring about the end of their personhood, or of their autonomy. Because the patient's autonomy is intimately linked to their relationships with others, once critical illness supervenes, respect for their autonomy devolves to those others with whom the patient is in relationship. In practical application, this means that there must be a dialogue, as the end-of-life of the critically-ill patient in ICU comes into view. Such dialogue should be grounded on this understanding in order to conform best to moral philosophical principles. Ideally the dialogue will involve all those with whom the patient is in relationship and, practical difficulties within an ICU notwithstanding, will aim to be inclusive, non-coercive and reflective as it seeks to maximise the good of the patient in their unique context.
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Affiliation(s)
- Paul Walker
- Clinical Unit in Ethics and Health Law, and Education, University of Newcastle, Callaghan, NSW, 2308, Australia,
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Berg K, Rise MB, Balandin S, Armstrong E, Askim T. Speech pathologists’ experience of involving people with stroke-induced aphasia in clinical decision making during rehabilitation. Disabil Rehabil 2015; 38:870-8. [DOI: 10.3109/09638288.2015.1066453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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