Journal of evaluation in clinical practice
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The causes of chronic fatigue syndrome (CFS) remain unknown, with many failures to replicate new findings. This may be because the condition is hard to diagnose, difficult to classify, or because of its heterogeneous nature. Authors have problems in differentiating CFS from myalgic encephalomyelitis (ME), which leads many to label it as a hybrid CFS/ME or ME/CFS. ⋯ An alternative approach is provided by studies suggesting that the condition is heterogeneous. The way forward may be to be over-inclusive regarding the diagnosis as a first step, while subdividing the condition into likely subgroups as a means of finding valid and reliable associations with potential causes. Studies of aetiology must involve prospective designs since cross-sectional studies cannot inform either aetiology or pathophysiology.
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Clinical guidelines are an increasingly common part of medical practice. The desire to standardize practices may seem a noble one, but overzealous application can make guidelines seem restrictive, leading to resentment or, worse, disregard. ⋯ Or where guidelines restrict access to services, utilitarianism might seem a better fit. Here, clinical practice guidelines are examined in terms of these theories of normative ethics, and it is argued that in fact, the process of writing and implementing guidelines is more accurately modelled through the lens of virtue ethics.
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There is a growing expectation of implementing shared decision making (SDM) in today's health care service, including mental health care. Traditional understanding of SDM may be too narrow to capture the complexity of treatments of mental health problems. Although the patients' contribution to SDM is well described, the contribution from the health care practitioners is less explored. Therefore, our aim was to explore the attitudes of practitioners in mental health care and the associations between practitioners' attitudes and SDM. ⋯ SDM in mental health care is complex and demands multifaceted preparations from practitioners as well as patients. The practitioners' attitudes are not sufficiently explored using one instrument. The positive association between practitioners' patient-centred attitudes and SDM found in this study implies a relevance of the practitioners' attitudes for accomplishment of SDM processes in mental health care.
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Observational Study
The impact of a patient decision aid on shared decision-making behaviour in oncology care and pulmonary medicine-A field study based on real-life observations.
A patient decision aid (PtDA) is often developed and evaluated to support shared decision making (SDM) and a patient-centred approach. In this study, a PtDA template was developed to support two different preference sensitive decisions: adjuvant therapy for breast cancer and diagnostic workup for lung cancer. The aim of the study was to explore whether a PtDA improved SDM and supported a patient-centred approach from an observational point of view. ⋯ Real-life observations and the use of a validated observational tool provided comprehensive knowledge as to how a PtDA affects SDM in consultations. Applying a PtDA resulted in a significant overall increase of SDM behaviour in decisions on adjuvant treatment after breast cancer surgery and diagnostic workup in case of a small suspicion of lung cancer. In conclusion, the PtDA supports SDM in consultations independently of type of decision and department.
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Shared decision-making takes many forms, involving different kinds of agents who share the requirement that they must have sufficient decision-making capacity for the decision in question. Advance care planning (ACP) is commonly viewed as a form of shared decision-making between carers and patients who anticipate losing decision-making capacity. What is unclear in this situation is the identity status of an individual who has become mentally incapacitated and how to evaluate their rights and interests. ⋯ Yet, an ACP framework based on narrative identity and the relevant capacities to construct such narratives results in more demanding capacity requirements than current medico-legal practice requires. The law thus espouses conflicting views as to who can be an appropriate decision-making authority for patient care. I therefore conclude that the law governing medical care needs to be clearer about how to resolve the identity problem and revisit its position on ACP or supported decision-making for those who have only focally preserved decision-making capacity.