When do health care decisions discriminate against persons with disabilities?

Recent interpretations of laws prohibiting discrimination against persons with disabilities indicate that these laws will play a greater role in health care decision making than previously anticipated. This article employs lessons from other areas of antidiscrimination law to examine these developments and to provide a framework for making health care decisions that are consistent with these new legal interpretations. This article addresses decisions in individual cases, treatment policies adopted by health care providers, and coverage programs of third-party payers, both public and private.     

Responsibilities of psychologists under guardianship and conservatorship laws.

Reviews guardianship and conservatorship laws relating to adults in all 50 states plus the District of Columbia to determine the allocation of responsibilities to mental health professionals. Six major points in guardianship and conservatorship proceedings are identified in which mental health professionals, qualified to evaluate and comment on individuals' competency to care for themselves and/or their property, can provide valuable input into a subsequent determination of such issues. It was found that psychologists are discriminated against under these laws. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Older adults prefer less choice than young adults.

Previous research has demonstrated that older adults prefer less autonomy and seek less information when making decisions on their own relative to young adults (for a review, see M. Mather, 2006). Would older adults also prefer fewer options from which to choose? The authors tested this hypothesis in the context of different decision domains. Participants completed a choice preferences survey in which they indicated their desired number of choices across 6 domains of health care and everyday decisions. The hypothesis was confirmed across all decision domains. The authors discuss implications from these results as they relate to theories of aging and health care policy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Minnesota public opinion on health care resource allocation

Creating workable policies for allocating or rationing finite health care resources to meet the needs of individuals as well as the broader society vexes policymakers, providers, and consumers. This paper presents results of a March 1994 Lou Harris survey of 1,006 Minnesotans about health care allocation. Minnesotans believe that allocative or rationing decisions are inevitable and can be discussed. Individualized bedside allocative decisions are preferable to categorical or universal exclusions of some health care benefits. People want comprehensive health care and are willing to let sound clinical judgment, perhaps informed by practice guidelines, selectively withhold some services. The integrity of plan-based allocation or rationing may be best secured and safeguarded by standards that ensure that the decisions are based on patients' best interests, involve trusted clinical decision makers, and include lay participation in the decision making.     

Aging, emotion, and health-related decision strategies: Motivational manipulations can reduce age differences.

According to socioemotional selectivity theory, age-related constraints on time horizons are associated with motivational changes that increasingly favor goals related to emotional well-being. Such changes have implications for emotionally taxing tasks such as making decisions, especially when decisions require consideration of unpleasant information. This study examined age differences in information acquisition and recall in the health care realm. Using computer-based decision scenarios, 60 older and 60 young adults reviewed choice criteria that contained positive, negative, and neutral information about different physicians and health care plans. As predicted, older adults reviewed and recalled a greater proportion of positive than of negative information compared with young adults. Age differences were eliminated when motivational manipulations elicited information-gathering goals or when time perspective was controlled statistically. Implications for improving decision strategies in older adults are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Insurance coverage, physician recommendations, and access to emerging treatments: growth hormone therapy for childhood short stature

CONTEXT: There is concern in both the medical community and the general public about mechanisms of medical decision making and the interplay of physician and insurer decisions in determining access to care. OBJECTIVE: To examine the medical process influencing access to growth hormone (GH) therapy for childhood short stature by comparing coverage policies of US insurers with the treatment recommendations of US physicians. DESIGN AND PARTICIPANTS: Independent national representative surveys were mailed to insurers (private, Blue Cross/Blue Shield, health maintenance organizations, programs for Children with Special Health Care Needs, and Medicaid programs, n=113), primary care physicians (n=1504), and pediatric endocrinologists (n=534) with response rates of 75%, 60%, and 81%, respectively. Each survey included identical case scenarios. Primary care physicians were asked decisions about referrals to pediatric endocrinologists. Endocrinologists were asked GH treatment recommendations. Insurers were asked coverage decisions for GH therapy. MAIN OUTCOME MEASURES: Insurer coverage decisions for GH in specific case scenarios were compared with the recommendations of primary care physicians and pediatric endocrinologists. RESULTS: Physician recommendations and insurance coverage decisions differed strikingly. For example, while 96% of pediatric endocrinologists recommended GH therapy for children with Turner syndrome, insurer policies covered GH therapy for only 52% of these children. Overall, referral and treatment decisions by physicians resulted in recommendations for GH therapy in 78% of children with GH deficiency, Turner syndrome, or renal failure; of those recommended for treatment, 28% were denied coverage by insurers. Similarly, GH therapy would be recommended by physicians for only 9% of children with idiopathic short stature, but insurers would not cover GH for the vast majority of these children. Furthermore, the data indicated considerable variation among insurers regarding coverage policies for GH (P<.01). CONCLUSIONS: Access to GH therapy differs depending on the type of insurance coverage. The deep discord between physician recommendations and insurance coverage decisions, exemplified by these findings, represents a major challenge to mechanisms of health care decision making, access, and costs.     

Medical decisions made by teams: carefulness and responsibility

To a growing extent, medical decision making takes place in the context of a team. Where multidisciplinary cooperation is necessary and the decisions to be taken are complex and consequential (in particular at the beginning and the end of life) joint decision making is considered an essential requirement of careful medical practice. From a legal point of view, this raises the question who is accountable for such decisions. Basically, accountability (and the liability that may result from it) will stay with the individual participants, and in particular with the first responsible, attending physician. In this respect, decision making in such situations is not basically different from other, more informal consultation structures (such as regular case reviews at department level) which are current practice in many health care institutions. Finally, if joint decision making is required, it should be clear in advance how decisions are to be arrived at in the team.     

Advance directives and advocacy in end-of-life decisions

This article examines the issue of advocacy for all adults in end-of-life decisions to help enhance the role of health care providers as partners in decision making. The ethical issues of death and dying are of particular concern for the elderly. Conflicts may prevent providers and nurses from creating a good dying experience for patients and family. Among the many issues associated with end-of-life decision making are futility, autonomy, and quality of life, a "good death," advance directives, family distress, and the culture of medicine. To overcome related barriers, involved health care providers can promote advocacy by offering choices in end-of-life care and providing an environment of listening and communication. Initiating and maintaining dialogue on this difficult subject will provide better care to patients and families.     

Rationing: a transatlantic perspective

Despite the differing mechanisms of health care delivery and financing in the United Kingdom and the United States many of the issues faced by the two countries are similar, most notably the increasing financial pressures. In both countries there have been recent changes in the allocation of resources and the mechanisms of decision making. Different criteria for determining resource allocation have been tried in the two health care systems. These developments change long traditions of rationing decisions at the individual patient level in the US, and of centralised government decision making in the UK.     

Projection in surrogate decisions about life-sustaining medical treatments.

To honor the wishes of an incapacitated patient, surrogate decision makers must predict the treatment decisions patients would make for themselves if able. Social psychological research, however, suggests that surrogates' own treatment preferences may influence their predictions of others' preferences. In 2 studies (1 involving 60 college student surrogates and a parent, the other involving 361 elderly outpatients and their chosen surrogate decision maker), surrogates predicted whether a close other would want life-sustaining treatment in hypothetical end-of-life scenarios and stated their own treatment preferences in the same scenarios. Surrogate predictions more closely resembled surrogates' own treatment wishes than they did the wishes of the individual they were trying to predict. Although the majority of prediction errors reflected inaccurate use of surrogates' own treatment preferences, projection was also found to result in accurate prediction more often than counterprojective predictions. The rationality and accuracy of projection in surrogate decision making is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prenatal diagnosis: choices women make about pursuing testing and acting on abnormal results

Liberalization of abortion laws in several US states (e.g., New York and California) coincided with the development of prenatal techniques, which diagnose chromosomal abnormalities and biochemical disorders. Increased use of prenatal diagnostic services has not been accompanied by adequate examination of the decision making process women undergo when contemplating prenatal diagnosis, pregnancy termination, or experimental fetal therapy. The limited literature exploring these issues indicates that many women do not know as much as possible about the health of their fetus. Women who are at risk of abnormal pregnancy tend to become distressed and willing to accept invasive testing, even when they know the significant, albeit low, risks of such testing. Women's perceptions of risk, which stem from complex psychologic-phenomena, are likely to be very inconsistent with objective reality. Neither counseling nor education can easily change these misperceptions. Nevertheless, counseling can at least alter misperceptions enough so they move closer to objective reality. On the other hand, counseling can sway perceptions and choices made based on these perceptions. Decision making is even more complex and emotional when women encounter abnormalities. Considerable social, moral, and psychologic factors influence this process, making this a very problematic area to study. Almost all women who carry an abnormal fetus with a very serious prognosis and a high degree of diagnostic certainty chose to terminate the pregnancy. The decision is much more difficult for women carrying a fetus with less diagnostic or prognostic certainty. Insufficient data exists to determine how they handle these management decisions. Women tend to opt for abortion in cases of chromosomal abnormalities, regardless of the severity or certainty of the outcome. Women carrying a fetus with anatomic disorders with prognostic uncertainty or less severity choose to abort at lower rates. More research is needed to understand decision making processes.     

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.     

Discourse comprehension and problem solving: Decisions about the treatment of breast cancer by women across the life span.

The 1st study examined the decision making and prose comprehension of 94 women interacting with an authentic, unfolding health scenario about breast cancer. The 2nd study involved questionnaire data focusing on the decisions made by 75 women who had been diagnosed with breast cancer. Two major findings emerged from this laboratory and survey research. First, older women sought less information when making treatment decisions about breast cancer. However, the outcome of those decisions were equivalent to those of younger women. Second, older women made these decisions faster than younger women. In addition, treatment decisions were related to prose processing, the type of information underlined as important while reading as well as the type of information remembered about various treatment options. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A guide to interpreting discordant systematic reviews

Systematic reviews are becoming prominent tools to guide health care decisions. As the number of published systematic reviews increases, it is common to find more than 1 systematic review addressing the same or a very similar therapeutic question. Despite the promise for systematic reviews to resolve conflicting results of primary studies, conflicts among reviews are now emerging. Such conflicts produce difficulties for decision-makers (including clinicians, policy-makers, researchers and patients) who rely on these reviews to help them make choices among alternative interventions when experts and the results of trials disagree. The authors provide an adjunct decision tool--a decision algorithm--to help decision-makers select from among discordant reviews.     

Historical evolution of inguinal hernia repair

In periods of change, psychiatric services must project outcomes of decisions about service innovations and reductions, including budgetary implications. To support such decision making, a public-sector psychiatric service in Melbourne, Victoria, Australia, developed a modeling tool that combines data from its service activity database and budgetary information with modeling techniques based on use of a spreadsheet. The model is based on clients' use of three major service components: the inpatient unit, continuing clinical care and consultancy services, and crisis assessment and treatment services. It classifies clients according to patterns of care-that is, whether they used one, two, or three of the components, in various combinations. The authors report service use and financial data derived from the model for the financial year 1992-1993. They describe two scenarios for using the model to project changes in patterns of care and costs when new services are implemented. Such a model can clarify costs, including opportunity costs, of management decisions and facilitate participation of senior clinicians in active service planning within the realities of budgetary constraints.     

Prion protein expression in Chinese hamster ovary cells using a glutamine synthetase selection and amplification system

BACKGROUND: Personnel working in neonatal intensive care units frequently face difficult ethical problems related to the initiation, maintenance or withdrawal of life support therapies. AIM: To assess the importance of ethical issues in the clinical decision making of health care providers in neonatal intensive care units. MATERIAL AND METHODS: A questionnaire based on five clinical vignettes that assessed judgments about quality of life, impact of parent's opinions and decision making in emergency situations and with different degrees of certainty, was designed. Eleven neonatologists and 20 nurses and midwives specialized in neonatology anonymously answered this questionnaire. RESULTS: There was a great inter individual variability in therapeutic approaches in cases with a bad vital and neurological prognosis. In cases of medical emergencies with uncertain diagnoses, bad vital prognosis but neurological indemnity, most professionals coincided in delivering all possible therapeutic options. Parent's opinions had a great impact in medical decisions, except when there was neurological indemnity. CONCLUSIONS: The specific responsibilities of the different agents in medical decision making must be delimited. Parents do not have absolute rights over their offspring and physicians must reject useless therapies.     

Considerations for ethical practice in managed care.

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Protecting patient welfare in managed care: six safeguards

The public is very suspicious and fearful that managed care threatens their health because of its interest in reducing costs. Because physicians' decisions control 75 percent of all health care spending, managed care organizations are focusing their cost-cutting strategies on influencing physician decision making through financial incentives and guidelines. These two techniques have had some important contributions, especially in enhancing efficiency and standardizing care to a high level. Nevertheless, they pose a threat--and are perceived by the public to pose a threat--to patients' health and well-being. How can we mitigate the threats to patient welfare posed by financial incentives and guidelines? We propose and analyze six safeguards. These safeguards are not an attempt to revive the fee-for-service system, but an effort to make managed care ethical and to focus it on improving patient welfare. They are designed to work together to ensure that patient welfare remains the primary focus of managed care organizations; they try to create institutional structures that emphasize quality over mere cost reductions.     

Religious advance directives: the convergence of law, religion, medicine, and public health

Because of the deep interpersonal significance of decisions made at the end of life, it is not surprising that religion has played an important role in patient and family decision making. Specific religious concerns about death and dying have led to religious advance directives. Advance directives offer a case study of models of interaction between religious communities and secular institutions. This paper examines why such directives have been created and how they may affect health care decisions. An analysis of their strengths and weaknesses concludes that specific religious instructions are unnecessary in written directives and may undermine both the religious and health care goals of patients.