Risk factors and clinical outcomes between fungal and bacterial keratitis: a comparative study

OBJECTIVE: Thirty years ago, cardiopulmonary resuscitation (CPR) was primarily developed for otherwise healthy individuals who experienced sudden cardiac arrest. Today, CPR is widely viewed as an emergency procedure that can be attempted on any person who undergoes a cessation of cardiorespiratory function. Therefore, the appropriateness of CPR has been questioned as a matter of the outcome, the patient's preferences, and the cost. The objective of this article is to analyse ethical issues in prehospital resuscitation. ARGUMENTS: CPR is bound by moral considerations that surround the use of any medical treatment. According to Beauchamp and Childress, the hierarchy of justification in biomedical ethics consists of ethical theories, principles, rules, and particular judgements and actions. The decision to start CPR is based on the medical judgement that a person is suffering from circulatory arrest. The decision is justified by the moral rule that the victim of a cardiac arrest has the right to survive and to receive CPR. Moral rules are more specific to contexts and are based on ethical principles. The principle of beneficence means the provision of benefits for the promotion of welfare. Talking about beneficence in resuscitation means once again reporting stories of success, as many victims of pre- and in-hospital sudden death have been saved in the past. Nevertheless, resuscitative efforts still remain unsuccessful in the majority of cases, involving the principle of nonmaleficence. There is potential harm in CPR. Survivors may recover cardiac function, but sustain severe hypoxic brain damage, at worst surviving without awakening for months or years. In particular, post-traumatic CPR is associated with an extremely poor outcome, leading to the issue of futility. However, futility should be defined in a strict fashion, as there might be an individual chance of survival. The principle of respect for autonomy means the right of a patient to accept or reject medical treatment, which continues in emergency conditions and after the patient has lost consciousness. The time frame in CPR requires medical decision-making within seconds, and CPR is usually initiated without the patient's involvement. If the patient's wish's can be ascertained later on, life-sustaining therapies might be withdrawn at the time. Terminally ill but still competent patients should be encouraged to write a no-CPR document, which does not deny patients relief from severe symptoms, but might facilitate withholding resuscitative efforts at the scene. The principle of justice affects priorities in the allocation of health care resources. The decision made for a particular patient might delay or prevent emergency treatment in other patients who could receive greater benefit. CONCLUSIONS: The standard of care remains the prompt initiation of CPR. However, ethical principles such as beneficence, nonmaleficence, autonomy, and justice have to be applied in the unique setting of emergency medicine. Physicians have to consider the therapeutic efficacy of CPR, the potential risks, and the patient's preferences.     

Microbiological quality of recreational waters in Araraquara, SP, Brazil

This replication of Ott's study [Ott, B. (1986). An Ethical Problem Facing Nurses: The Support of Patient Autonomy in the Do Not Resuscitate Decision. University Microfilms International, Dissertation, Texas Women's University] and McLaughlin et al.'s study [McLaughlin, T., Brown, O. and Herman, J. (1988). Nurses' Perception of the Support of Patient Autonomy in Do Not Resuscitate Situations. Unpublished Research Report] explored hospital staff nurses' perceptions of their role in supporting patient autonomy in the do-not-resuscitate (DNR) decision. One-hundred and sixty-five registered nurses (RNs) participated: 93 from the Veterans Administration Medical Center and 72 from a private non-profit hospital. Ott's questionnaire had four hypothetical cases in which a DNR decision would probably be made with three questions about whose opinion would most support patient autonomy and whose opinion would actually be regarded as the most appropriate for making the DNR decision. Seventy per cent of perceptions of the person whose decision would be best able to support the patient's autonomy in the DNR decision and 51% of the people perceived to actually be deemed most appropriate to make the DNR decision were consistent with Ott's DNR Decision Model.     

Juror decision-making models: The generalization gap.

Evaluates psychological and mathematical models that have been applied to individual juror decision making and identifies 3 research goals: to gain insight into adult cognition in a complex, naturally occurring reasoning task, to extend existing psychological models of decision making and judgment, and to provide empirical data on questions of interest to the legal community. A task analysis is presented in the form of an ideal juror model to describe and evaluate empirical research with respect to these goals. Component processes proposed in each model and empirical findings are compared across models and in relation to the task analysis. Models examined include information integration, Bayesian, Poisson, sequential weighting, and nonmodels. It is concluded that laboratory model applications to actual complex reasoning tasks must be based on thorough task analyses to avoid conflict between research goals and to facilitate generalization to natural settings. (130 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.     

The frequency of "do-not-resuscitate" order in aged in-patients: effect of patient- and non-patient-related factors

OBJECTIVE: The purpose of this study was to examine the effect of patient- and non-patient-related factors (co-morbidity, demographics, and method of surveillance) on the frequency of "do-not-resuscitate" (DNR) orders in aged inpatients. METHODS: On a geriatric ward, during three different periods within 1 year, we used two different methods of data collection (with or without a form) and two different time-frames (prevalence or incidence) in studying the frequency of DNR orders, demographic data and the Pre-Arrest Morbidity (PAM) Index. RESULTS: In a sample of 261 patients the DNR decision was related to patient-related factors, including the PAM score and age. Only 3 patients with a score above 4 had no DNR order and in the group of 142 patients > 83 years 85 (59.9%) had a DNR order, compared to 52 (43.7%) of the 119 patients of 83 years or less (p < 0.05). In contrast, gender and marital status were not related to the presence of a DNR order. The variables PAM score, age, form and time-frame classified 76.6% of the cardiopulmonary resuscitation (CPR) decisions correctly and 71.5% of the DNR decisions correctly. Without attention to the resuscitation decision, the written DNR order frequency decreased significantly from 64-59% to 23%. An explanation for this variance may be the passive process of data collection, a non-patient-related factor. CONCLUSIONS: The DNR decision is related to the PAM index score and age. The variance in DNR decisions is partly related to the method of data collection, a non-patient-related factor in DNR decision-making. Without attention to the DNR/CPR decision, the DNR frequency decreased markedly.     

The relationship between moral decision making and patterns of consolidation and transition in moral judgment development.

Following models that describe intraindividual correlates of stage transitions (S. S. Snyder & D. H. Feldman, 1984), this study assessed the relation between a measure of consolidation and transition in moral judgment development and the utility of moral concepts in sociomoral decision making. The study extends previous research in suggesting that individuals use moral concepts differently as they cycle through periods of consolidation and transition. With multiple cross-sectional and longitudinal samples, findings indicate that participants' reliance on a Kohlbergian moral framework as measured by the Defining Issues Test is highest during periods of consolidation and lowest during transitions. As participants move into periods of consolidation, the utility of moral stage information increases. Thus, this study indicates that the consolidation and transition model can be used to help identify individuals who are more or less likely to use Kohlberg's moral stages in their moral decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Venlafaxine''s effects on healthy volunteers'' driving, psychomotor, and vigilance performance during 15-day fixed and incremental dosing regimens

Patients, providers, and families are increasingly involved in end-of-life decisions (advance directives, health care proxy, do-not-resuscitate [DNR] status consents). These decisions can be complex processes whereby the participants in the process must come to terms with often painful and difficult decisions. The role perception of the nurse in end-of-life decision making is not well delineated. This chapter explores the results of a study that addresses the question, "What are the experiences of oncology nurses as they interact with patients and/or family members during the process of patients/families signing DNR consents. The grounded theory method of data collection and analysis was used to explore this question. The results of the study indicate that central to the process of consenting to DNR status is the degree of shared understanding about the meaning of DNR status among participants and the conflict that can occur when meanings are not shared. A model is presented that illustrates the connections between the meanings of DNR (patient, family, and provider) and congruence and conflict in the DNR consent process. Strategies are discussed that facilitate prevention or resolution of conflict in the DNR status decision-making process. Strategies used by the nurse to facilitate decision making by patient and families include communicating with, caring for, educating, advocating for, and collaborating with patients, families, and other providers.     

Nursing home resuscitation policies and practices for residents without DNR orders

The purpose of this study was to explore the policies and practices of nursing homes with respect to the resuscitation of residents who do not have a do-not-resuscitate (DNR) order. Responses from a survey of 36 facilities revealed that most residents had DNR orders and most facilities were capable of providing basic cardiopulmonary resuscitation (CPR). Less than 30% had performed CPR in the past 6 months, and 22.8% had no written CPR policies. More facilities required CPR in witnessed arrests of non-DNR residents (79.3%) than in unwitnessed arrests (24%). Methods for identifying CPR status need improvement to enable accurate identification and prompt resuscitation of residents who want CPR.     

'Do not resuscitate': How? why? and when?

OBJECTIVE: The main objective was to discover who had 'Do Not Resuscitate' (DNR) status, why, how, when and by whom these decisions were made. DESIGN, SETTING AND PATIENTS: The medical and nursing notes of all inpatients (139) (age range 16-100 years) in an inner city district general hospital on a single day were examined to determine the resuscitation status, age, sex, and diagnosis of each patient. RESULT: A decision not to resuscitate had been taken in 28 (20%) of the cases. 'Do Not Resuscitate' (DNR) patients were significantly older and more likely to suffer from malignant and cardiorespiratory disease. Patients with dementia and other psychiatric disorders were not significantly more often labelled DNR. Evidence of consultation for these decisions was lacking and the recording erratic. CONCLUSIONS: (1) There is a great need to devise and implement comprehensive guidelines. (2) There is need for appropriate and comprehensive documentation outlining the reasons why and how the decision was taken, who was consulted and review date. (3) This is an important area for audit.     

Benevolence, a central moral concept derived from a grounded theory study of nursing decision making in psychiatric settings

Fourteen experienced nurses participated in an explorative study aimed at describing the experiential aspects of moral decision making in psychiatric nursing practice. In-depth interviews were conducted according to the grounded theory method. These were transcribed, coded and categorized in order to generate conceptual categories. The concept of benevolence was identified as a central motivating factor in the nurses' own accounts of situations in which decisions were made on behalf of the patient. This seems to conceptualize the nurses' expressed aim to do that which is 'good' for the patient in responding to his or her vulnerability. This study indicates the need for further research into the subjective, experiential aspect of ethical decision making from a contextual perspective.     

Adolescent moral judgment and perceptions of family interaction.

Oakland Growth Study (H. E. Jones, 1939) Ss and 98 adolescent offspring (qged 10–18 yrs) responded to Kohlberg Moral Judgment Interviews (A. Colby et al, 1987) and reported their perceptions of family interaction during 2 waves of longitudinal follow-up at the Institute of Human Development, University of California, Berkeley. Relationships between adolescent moral judgment and parent and adolescent perceptions of family structure, decision making, value orientation, moral transmission, and interpersonal relationships were assessed, with age, sex, IQ, and parent moral judgment controlled. Adolescent moral judgment was most consistently related to reports of positive intrafamilial relationships and cognitive stimulation of moral reasoning. Sex differences in relationships between family interaction and moral judgment were also found. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Moral judgment in delinquent and nondelinquent adolescents and their mothers.

Although considerable research effort has been devoted to the investigation of moral judgment in normal children, the relationship of the child's moral judgment to significant moral conduct as well as to parental antecedents has received scant empirical attention. In the current research, the level of moral judgment of 10 male 14-16 yr old delinquents and their mothers was compared to 10 nondelinquent males (matched on IQ and age) and their mothers, using L. Kohlberg's structured moral dilemmas. Mothers in both groups combined were higher in moral judgment than their sons. Nondelinquent adolescents used higher stages of moral judgment than delinquent adolescents. Similarly, mothers of nondelinquents manifested more mature moral judgment than did mothers of delinquents. Parental influences on the moral development of the child are discussed. (29 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Risk Assessment as an Integral Aspect of Capacity Evaluations.

Objective: To highlight the need for rehabilitation psychologists' evaluation of potential risks when examining an individual's decision-making capacity (DMC). Design: A literature review of research regarding decision making, predictive accuracy, and rehabilitation outcomes. Conclusions: The perceived level of risk or potential harm entailed in a decision determines the "sliding scale" for DMC. There is much less research on risk assessment than on the cognitive components needed for DMC, meaning that clinicians usually have to rely on clinical judgment. Clinical judgment is often inaccurate in terms of identifying factors that could increase the risk for harm and is susceptible to errors when predicting future risk. It is therefore argued that the process of assessing an individual's DMC must be matched by an equally rigorous analysis of clinicians' ability to quantify situational risk. Only when these 2 components are properly considered can an adequate standard for DMC be established. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fifteen things you should know about new Maryland laws when making health care decisions

Recent dramatic changes to Maryland law regarding health care decision making for incapacitated patients will have significant impact on the role of physicians in making these decisions. On October 1, 1993, the newly passed Maryland Health Care Decision Act took effect, and revisions to state guardianship laws were implemented. The laws, which Governor Schaefer approved on May 11, 1993, modify existing statutory language pertaining to the four legal tools available for making health care decisions for a person when he or she becomes incapacitated: (1) living wills, (2) substituted consents for medical procedures, (3) health care power of attorney appointments, and (4) guardianship proceedings. This article summarizes 15 important points in these new or revised Maryland laws on health care decision making.     

The development and application of a scale of acculturation

As Australia is one of the most multicultural societies in the world, acculturation of migrants and changes in migrants' health status should be an important focus of public health research. The absence of an accepted measure of acculturation is one barrier to exploring the relationship between acculturation and health. This paper presents data from a study of 851 Arabic-speaking adults attending 20 Arabic-speaking general practitioners in Canterbury, Sydney. An eight-item scale assessing acculturation was developed with a structural equation modelling program (LISREL). This acculturation scale was based on similar scales used with Hispanic populations, was theoretically grounded and had high internal consistency and criterion-related validity. To show the application of a scale of acculturation, patients' preferences for participation in medical decision making, according to level of acculturation, were examined. After adjustment for age, sex and highest level of formal education, significant inverse associations between acculturation and preferences for patient (versus family) involvement in medical decision making were found. Mechanisms for how acculturation affects health need to be explored.     

Role taking and moral judgment in five- and seven-year-olds.

Studied 3 dimensions of role taking (perceptual, cognitive, and affective) and 2 dimensions of moral judgment (intentionality and restitution) in 34 kindergartners and 38 2nd graders. Results show that there was a significant correlation between moral judgment and role taking and indicate the need for precise definitions of these concepts and the use of common instruments if research in this area is to make any progress. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Electric nerve stimulation (ENS): 70 clinical cases of bi-block aided by an electric bipolar signal

The paper describes medical informatics discipline and deals with decision support systems in more details. It describes the process of decision making using diagnostic and therapeutic decision making cycle and two sources of medical knowledge-scientific and empirical knowledge. It shows different approaches for development of computer supported decision systems and presents some examples of their use in medical practice.     

Hysterectomy: improving the patient's decision-making process

Increasingly, patients are expecting to be more involved than they traditionally have been in medical and surgical decision making. The unilateral process of informed consent is evolving into one of informed collaborative choice. Hysterectomy is a procedure that is frequently performed when reasonable surgical and nonsurgical alternatives remain. When professional consensus as to the clear recommendation for hysterectomy is not present, patient choice is particularly important. Because more than 80% of health-care decisions, including those in which one of the choices is hysterectomy, are elective, gynecologists and other health care providers increasingly will need to develop more efficient and collaborative methods to integrate patient autonomy and choice into the decision-making process. There is mounting evidence that both clinical and nonclinical outcomes (satisfaction and cost) may be improved when properly informed consumers collaborate in making medical and surgical decisions. Legal liability for adverse outcomes may be decreased by increased patient participation in medical and surgical decision making. The era of managed care has created an agency problem stemming from the fact that consumers (patients) are concerned that necessary procedures and other treatments may be withheld because of cost considerations. Health plans and medical groups likely will be required to provide objective information about the options that consumers (patients) have when faced with choices, including decision making and hysterectomy. By incorporating patient expectations and preferences as part of the process of decision making, an ethically acceptable and effective method of "rationing by patient choice" may be feasible. Figure 3 is a graphic depiction of such a process of informed collaborative choice progressing from effective choices through efficient choices and then to the one providing the best value for an individual patient.     

Designing and validating a measure of moral judgment: Stage preference and stage consistency approaches.

The Defining Issues Test (DIT) of moral judgment is discussed in light of the recent challenge by C. Lind (1995) with the Moral Judgment Test (MJT), which is widely used in Europe. The 2 tests represent alternative methods as well as support different conclusions about moral judgment. The key difference is a stage-consistency (MJT) vs. a stage-preference (DIT) approach. Construct validity is defined in terms of 7 types of studies, and the approaches are compared. The stage-preference approach systematically outperforms the stage-consistency approach. Benchmarking by using classic studies in moral judgment illustrates an empirical, multistudy, quantitative approach to moral judgment research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)