scholarly journals “Thinking Too Much”: A Clash of Legitimate Values in Clinical Practice Calls for an Indaba Guided by African Values-Based Practice

2020 ◽  
pp. 179-187
Author(s):  
Werdie Van Staden
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
General Practitioner ◽  
Antipsychotic Medication ◽  
Common Ground ◽  
Medical Advice ◽  
Against Medical Advice ◽  
Difficult Decision ◽  
Decision Points ◽  
Major Decision

AbstractThis chapter applies African value-based practice (A-VBP) to the story of Akanya at two major decision points when values clashed: first between the general practitioner and Akanya’s parents when Akanya was acutely psychotic and required hospitalisation and second 8 years later, when Akanya wanted to discontinue his antipsychotic medication against medical advice. For both rather difficult decision points, the story illustrates how an indaba within A-VBP served as a practical process to take seriously and account for values that were clashing (i.e., uncommon ground), framed by values that were shared (i.e., common ground). The story underscores that dissensual decision-making affords more than default responses such as “I offer only what is medically best—take it or leave it” or alternatively “whatever the patient wants.”

VIGNETTE-BASED DECISION POINT ANALYSIS (VDPA): A NOVEL METHOD OF EXPLORING PERSON-CENTERED CONTEXTUAL INFLUENCES ON CLINICAL DECISION-MAKING

2015 ◽  
Vol 3 (2) ◽  
pp. 151
Author(s):  
Sisira Dharmaratne ◽  
Husna Razee ◽  
Gominda Ponnamperuma ◽  
Kosala Marambe ◽  
Andrew Dawson ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Clinical Decision Making ◽  
Field Research ◽  
Clinical Decision ◽  
Contextual Influences ◽  
Innovative Method ◽  
Decision Points ◽  
Point Analysis ◽  
Natural Settings

Rationale and aims: Contextual factors are increasingly recognized as having a significant influence on clinical-decision-making. Contextual influences however, are considered ‘less scientific’ or ‘non-clinical’ in the eyes of practicing clinicians, making it a sensitive issue for discussion.  Therefore, exploring these contextual influences can be challenging. Methods which can circumvent this challenge are required to evaluate clinical decision making at natural settings. This paper reports on the development of an innovative research method to address this challenge of exploring contextual influences and similar sensitive and complex clinical practice issues.  Method: The researchers conducted a field research to test an interview based method which was termed as ‘Clinician Recalled Vignette (CRV) Method’. Based on reflections on the field research experience this preliminary method was refined to develop an innovative method which is potentially capable of eliciting sensitive and complex clinical practice issues. Results: Reflections on field test data provided preliminary evidence on the usefulness of the CRV method and limitations. The method that was refined, in response to limitations, focused on key decision points relevant to the clinical vignettes recalled by clinicians, and included a mechanism to identify how contextual factors influence these key decision points. This innovative method was termed ‘Vignette-based Decision Point Analysis’. Conclusions: The innovative method discussed in this paper will assist other researchers in conceptualising and conducting research projects to explore sensitive and complex clinical practice issues in natural settings. 

Disputes about the Withdrawal of Treatment: The Role of the Courts

2004 ◽  
Vol 32 (4) ◽  
pp. 701-707 ◽  
Author(s):  
Loane Skene
Keyword(s):  
Decision Making ◽  
Human Rights ◽  
Medical Advice ◽  
Treatment Regime ◽  
Best Interests ◽  
Against Medical Advice ◽  
Turn On ◽  
Limited Success ◽  
Withdrawal Of Treatment

It is commonly said that patients (or their representatives) have no right to demand that treatment must be continued when medical carers believe it is “futile” to continue it. There are certainly many judicial statements to this effect, some of which are quoted in this paper. However, there are various ways that courts can intervene, even if they do not order directly that treatment must be provided or continued. First, patients or their representatives may argue the process of decision making was unfair or that they were unfairly discriminated against when treatment has been refused. To date, these arguments have met with limited success so far as enabling patients to have treatment provided or continued against medical advice. More recently, however, some patients have challenged the lawfulness of a proposed treatment regime by advancing human rights arguments, based in turn on a broader aspect of patients’ “best interests” than best medical interests.

scholarly journals Discharge against medical advice (DAMA) in paediatrics: An approach to promote safety and ethics

2019 ◽  
Vol 25 (1) ◽  
pp. 12-15
Author(s):  
Aifric Kavanagh ◽  
Olivia Ostrow ◽  
Randi Zlotnik Shaul
Keyword(s):  
Decision Making ◽  
Medical Advice ◽  
Informed Decision ◽  
Best Interests ◽  
Informed Decision Making ◽  
Process Map ◽  
Against Medical Advice ◽  
Professional Obligations ◽  
Discharge Against Medical Advice ◽  
Reference Tool

Abstract Requests for discharge against medical advice are often challenging for clinicians to navigate, especially when the patient is a child. An informed, standardized approach to managing situations where children and their families are requesting to leave against medical advice is essential to maximizing safety and ethics for patients and staff, yet such situations are often not handled this way. Paediatric discharge against medical advice (DAMA) requests are best managed when clinicians ensure the patient’s best interests are met, understand and act upon their professional obligations, and engage in guided discussion with patients and families that involves both shared and informed decision-making strategies. A process map can capture these criteria and readily provide clinicians with a bedside reference tool when managing paediatric DAMA requests.

BUILDING DECISION SUPPORT PROBLEM DOMAIN ONTOLOGY FROM NATURAL LANGUAGE REQUIREMENTS FOR SOFTWARE ASSURANCE

2006 ◽  
Vol 16 (06) ◽  
pp. 851-884 ◽  
Author(s):  
SEOK-WON LEE ◽  
DIVYA MUTHURAJAN ◽  
ROBIN A. GANDHI ◽  
DEEPAK YAVAGAL ◽  
GAIL-JOON AHN
Keyword(s):  
Decision Making ◽  
Decision Support ◽  
Natural Language ◽  
Knowledge Engineering ◽  
Domain Ontology ◽  
Problem Domain ◽  
Difficult Decision ◽  
Engineering Software ◽  
Decision Points ◽  
Software Intensive

The process of engineering software-intensive systems that comply with their Certification and Accreditation (C&A) requirements involves many critical decision-making activities for the related stakeholders. Considering the exhaustive nature of C&A activities together with the complexity of software-intensive systems, effective decision making relies heavily on the ways to understand and structure the problem domain concepts concerning decision points for interpretation, applicability, scope, evaluation, and impact of the enforced C&A requirements. These decision points are further complicated by natural language specifications of inherently non-functional C&A requirements scattered across multiple regulatory documents with complex interdependencies at different levels of abstractions in the organizational hierarchy, which often result in subjective interpretations and non-standard implementations of the C&A process. To address these issues, we define a systematic methodology using novel techniques from software Requirements Engineering (RE) and knowledge engineering for understanding and structuring the problem domain concepts based on a uniform representation format that promotes common understanding among stakeholders. Specifically, we use advanced ontological engineering techniques driven by theoretical RE foundations to systematically elicit, model, understand, and analyze problem domain concepts concerning significant and difficult decision points throughout the C&A process. We demonstrate the appropriateness of our methodology in creating decision support problem domain ontology using several examples derived from our experiences on automating the Department of Defense Information Technology Security C&A Process (DITSCAP).

Choices, Choices: The Application of Multi-Criteria Decision Analysis to a Food Safety Decision-Making Problem

2008 ◽  
Vol 71 (11) ◽  
pp. 2323-2333 ◽  
Author(s):  
A. FAZIL ◽  
A. RAJIC ◽  
J. SANCHEZ ◽  
S. MCEWEN
Keyword(s):  
Decision Making ◽  
Food Safety ◽  
Decision Analysis ◽  
Common Ground ◽  
Decision Makers ◽  
Analysis Approach ◽  
Weight Of Evidence ◽  
Multi Criteria Decision Analysis ◽  
Difficult Decision ◽  
Safety Interventions

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.

Factors Affecting Discharges against Medical Advice in an Emergency Department of a Tertiary Care Center

2020 ◽  
Vol 2 (2) ◽  
pp. 31-35
Author(s):  
Trishna Shrestha ◽  
Sneha Pradhananga ◽  
Kabita Hada Batajoo ◽  
Manjita Bajracharya
Keyword(s):  
Health Care ◽  
Emergency Department ◽  
Health Care Costs ◽  
Medical Advice ◽  
Health Concern ◽  
Against Medical Advice ◽  
Factors Affecting ◽  
Tertiary Center ◽  
Care Costs ◽  
Leaving Against Medical Advice

Introduction: Patients leaving against the advice of the treating team before being certified as fit is a major concern and challenge for the treating professionals as it possesses adverse medical outcomes. This study hence aimed at identifying the prevalence and major factors affecting such discharges so that advocacy can be done to help prevent it. Methods: A descriptive cross-sectional study was conducted at emergency department of a tertiary center in Lalitpur from 15th May 2019 to 15th August 2019. All the patients visiting the emergency department were included in the study and a non-probability purposive sampling method was used excluding the patients who denied giving reasons for them leaving against medical advice. Data was collected using pre-structured questionnaire and analyzed using SPSS-v21 software. Results: A hundred and fifteen patients (4.08%) left against medical advice out of 2812 patients who presented to emergency department. There were 63 male patients (54.8%), 75 patients of the total patients in the age group of 15-44 years (65.2%) and those living within a distance of 1km from the hospital (53%). The most common reason for the patients leaving against medical advice was found to be due to financial constraint (38.3%) followed by preference to other hospitals (16.5%). Conclusion: Patients leaving against medical advice possesses a small percentage of actual hospital admissions but is still a major health concern as it drastically increases the morbidity, re-admission rates and total health-care costs. Hence, understanding the general characteristics and predictors of such discharges is of utmost importance to help improve the patient outcome and reduce the health-care costs.  

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