Medical decision making : an international journal of the Society for Medical Decision Making
-
Comparative Study
Modal preferences predict elderly patients' life-sustaining treatment choices as well as patients' chosen surrogates do.
The purpose of this study was to compare the accuracy of an actuarial method of predicting patients' preferences for life-sustaining treatment with the accuracy of surrogate decision makers. 401 outpatients 65 years old or older (mean = 73 years) and their self-designated surrogate decision makers recorded preferences for four life-sustaining medical treatments in nine hypothetical illness scenarios. The surrogates did not predict the patients' preferences more accurately than did an actuarial model using modal preferences. Surrogates' accuracy was not influenced by the use of an advance directive (AD) or discussion of life-sustaining treatment choices. In clinical practice, an actuarial model could assist surrogate decision makers when a patient has no AD, an AD is unavailable, a patient's AD is vague or describes treatment choices for only extreme or unlikely disease states, no proxy decision maker has been designated, or a patient was never competent.
-
Local tailoring of clinical practice guidelines (CPGs) requires experts in medicine and evidence synthesis unavailable in many practice settings. The authors' computer-based system enables developers and users to create, disseminate, and tailor CPGs, using normative decision models (DMs). ⋯ The results demonstrate the feasibility of a web-based system that automatically analyzes a DM and creates a CPG as an annotated algorithm, enabling remote users to develop site-specific CPGs. In the pilot evaluation, the ALCHEMIST guidelines met established criteria for quality and compared favorably with national CPGs. The high usability and usefulness ratings suggest that such systems can be a good tool for guideline development.
-
Multicenter Study Comparative Study
Development of a pediatric multiple organ dysfunction score: use of two strategies.
An organ dysfunction (OD) scoring system for critically ill children is not yet available, and the method for developing such a system is not well defined. The aim of this study was to compare two developmental methods for assessing OD in critically ill children. ⋯ The PELOD system was more discriminant and had the advantage of taking into account both the relative severities among ODs and the degree of severity of each OD.
-
Patients with end-stage renal disease (ESRD) may have quality-of-life (QOL) concerns that are not fully appreciated by their providers. The authors conducted focus groups with dialysis patients and dialysis professionals to determine whether this qualitative method would reveal differences between patients' and providers' views about: 1) domains of QOL that are affected by ESRD and dialysis; and 2) aspects of dialysis that affect QOL. ⋯ Although health professionals have a good understanding of patient concerns about the effects of ESRD and dialysis, the focus group discussions revealed a breadth and depth of QOL concerns that they may not fully appreciate.
-
Clinicians recognize the importance of eliciting patient preferences for life-sustaining care, yet little is known about the stability of those preferences for patients with serious disease. ⋯ Health care providers should periodically reassess preferences for life-sustaining care, particularly for patients with progressive disease, given the instability in patient preferences. However, predictors of instability may vary with how preferences are measured. In particular, changes in health status may be related to instability of preferences for certain types of treatments.