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Biomedical subjects

Peter A Singer

Publications and source records attributed to Peter A Singer.

At least 55 records · Page 3Linked to original sources
PubMed2003

Interdisciplinary research: putting the methods under the microscope.

BACKGROUND: While the desirability of interdisciplinary inquiry has been widely acknowledged, indeed has become 'the mantra of science policy', the methods of interdisciplinary collaboration are opaque to outsiders and generally remain undescribed. DISCUSSION: Many have analysed interdisciplinarity, especially in relation to the creation of new disciplines and institutions. These analyses are briefly outlined. Still, there currently persists a silence about the methods of interdisciplinary collaboration itself, and the core of this paper proposes a template for such methods. SUMMARY: Breaking this silence--by making the methods of interdisciplinary projects transparent--could further invigorate interdisciplinary research.

Academies and Institutes↗
PubMed2003

Priority setting in surgery: improve the process and share the learning.

Surgeons and surgical programs encounter priority-setting challenges every day, such as in regard to purchasing new technologies or managing waiting lists for elective surgery. The purpose of this paper was to explore priority setting in surgery. Traditionally in surgery, priority-setting decisions for new technologies have been based on evidence of effectiveness and cost-effectiveness; and decisions about managing waiting lists for elective surgery have been based on urgency rating scores. The fairness of priority-setting processes in surgical programs should be enhanced to permit all relevant information and values to be considered. The quality of these decisions can be improved by using an approach that captures and shares lessons from each priority-setting experience. The approach we propose in this paper- describe, evaluate, and improve using a leading conceptual framework for priority setting, called "accountability for reasonableness"-can be used by any surgical program to improve its priority setting, share lessons with others, and develop an evidence base for how these important health policy decisions should be made.

Biomedical Technology↗
PubMed2003

CPR for patients labeled DNR: the role of the limited aggressive therapy order.

Patients who sustain a cardiac arrest have a less than 20% chance of surviving to hospital discharge. Patients may request do-not-resuscitate (DNR) orders if they believe that their chances for a meaningful recovery after cardiopulmonary arrest are low. However, in some identifiable circumstances, cardiopulmonary resuscitation (CPR) has a higher chance of success and lower likelihood of neurologic impairment. The probability of survival from a cardiac arrest influences patients' wishes regarding resuscitation; thus, when CPR has a higher likelihood of success, patients' expressed preferences for treatment as contained within a DNR order may not accurately reflect their intended goals. Patients should be offered the option of consenting to CPR for "higher-success" situations, including a witnessed cardiopulmonary arrest in which the initial cardiac rhythm is ventricular tachycardia or fibrillation, cardiac arrest in the operating room, and cardiac arrest resulting from a readily identifiable iatrogenic cause. This new level of resuscitation could be called a "limited aggressive therapy" order.

Cardiopulmonary Resuscitation↗
PubMed2003

Postoperative endocrine management of pituitary tumors.

Pituitary tumors are common and are often associated with endocrine abnormalities. Furthermore, pituitary surgery itself may result in additional hormonal changes, including impairment of anterior pituitary hormone secretion and, more commonly, abnormalities of ADH regulation. Endocrine management of patients with pituitary or other sellar lesions involves acute hospital-based and longer term office-based evaluation and treatment. In the immediate postoperative period, careful attention must be directed toward sodium and water balance as well as toward recognition of changes in endocrine function. Postoperative measurement of serum hormone levels also helps to determine if resection of a hypersecreting tumor has been successful. To minimize postoperative morbidity, perioperative endocrine assessment and management of patients undergoing pituitary surgery should consist of a team approach, involving both the neurosurgeon and the endocrinologist.

Diabetes Insipidus↗
PubMed2003

Intensive care nurses' and physicians' experiences with demands for treatment: some implications for clinical practice.

OBJECTIVE: This study was conducted to develop an empiric description of intensive care unit (ICU) physicians' and nurses' (participants) experiences providing life-sustaining treatments at the insistence of family members, treatments that they believed should have been withheld or withdrawn. From this description, steps to minimize or prevent their sources of distress in such situations are suggested. DESIGN: Semistructured, open-ended interviews. Participants were asked to describe cases in which treatment had been provided primarily in response to demands from family members. PARTICIPANTS: Six physicians and 6 nurses from 6 university-affiliated ICUs in Canada. All were members of a task force developing a multicenter policy to address demands for treatment, and physician members were heads of their ICUs. OUTCOME MEASURES: Systematic analysis of interview transcripts and synthesis of findings. RESULTS: Participants recalled 28 cases in which treatment had been provided at the insistence of family members. Many cases described were very distressing for both medical staff and family members. Consistently problematic areas included: (1) suffering of dying patients, (2) the marked distress of family members, and (3) a breakdown in the relationship between care providers and families. CONCLUSIONS: Conflict with family members about decisions to limit life-sustaining treatment can be very stressful for health care providers. Three important areas that give rise to distress were identified in this study. These key sources of distress should be looked for. They could be addressed by: (1) identifying to family members the importance of minimizing suffering and ongoing bodily injury of patients at risk for dying, (2) by doing so addressing directly the distress of family members by the provision of emotional support, and when appropriate directed toward helping them accept that the patient is dying, and (3) pursuing efforts to maintain or create a good relationship with family members despite disagreement about the appropriateness of continuing life-sustaining treatment.

Decision Making↗
PubMed2003

Seasonal bed closures in an intensive care unit: a qualitative study.

OBJECTIVE: To describe perceptions of the administrative procedures for seasonal bed closures and their consequences in the intensive care unit (ICU), and to critique this example of health care priority setting for legitimacy and fairness. DESIGN: A qualitative study using case study methods and interviews with key participants. We evaluated fairness and legitimacy of the bed closure process using 4 domains of the ethical framework of "accountability for reasonableness." SETTING: An university-affiliated medical/surgical ICU in Eastern Canada. PARTICIPANTS: ICU clinicians (9 bedside nurses and 5 physicians), and administrators (3 ICU managers and 2 senior hospital executives). MAIN OUTCOME MEASURES: Perceptions of ICU clinicians and administrators regarding the ICU bed closure decision-making process and its consequences. RESULTS: Emerging themes concerned: (1) bed closure rationale (including arbitrary decision making, bed closure masquerading as a code for a nursing shortage, and suboptimal evidence base for implementing closures); (2) bed closure process (viewed as unclear with insufficient prior publicity and inadequate subsequent review); and (3) adverse consequences (including safety issues, negative professional working relationships, and poor morale). Although an appeals mechanism existed, nurses were not available to staff reopened beds so this condition is only partially met. The relevance, publicity, and enforcement conditions for accountability of reasonableness were not satisfied, offering opportunities for improvement. CONCLUSION: Clinicians and administrators are readily able to identify shortcomings in the seasonal bed closure process in the ICU. These shortcomings should be targeted for improvement so that intensive care health services delivery is legitimate and fair.

Decision Making↗
PubMed2003

Priority setting in a hospital critical care unit: qualitative case study.

OBJECTIVE: To describe priority setting for admissions in a hospital critical care unit and to evaluate it using the ethical framework of "accountability for reasonableness. DESIGN: Qualitative case study and evaluation using the ethical framework of accountability for reasonableness. SETTING: A medical/surgical intensive care unit in a large urban university-affiliated teaching hospital in Toronto, Canada. PARTICIPANTS: Critical care unit staff including medical directors, nurses, residents, referring physicians, and members of a hospital committee that formulated an admissions policy. INTERVENTIONS: Modified thematic analysis of documents, interviews with participants, and direct observation of critical care unit rounds. Evaluation using the four conditions of Daniels and Sabin's accountability for reasonableness: relevance, publicity, appeals/revisions, and enforcement. MEASUREMENTS AND MAIN RESULTS: We examined key features and participants' views about the priority setting process. Decisions to admit patients involve a complex cluster of reasons. Both medical and nonmedical reasons are used, although the nonmedical reasons are less well documented and understood. Medical directors, who are the chief decision makers, differ in their reasoning. Admitting decisions and reasons are usually explained to referring staff but seldom to patients and families, and nonmedical reasons are seldom surfaced. A hospital critical care admissions policy exists but is not used and is not known to all stakeholders. A formal appeals/revisions process exists, but appeals usually involve informal negotiations. The existence of priority programs in the hospital (e.g., transplantation) adds complexity and heightens disagreement by stakeholders. CONCLUSION: We have described and evaluated admissions decision making in a hospital's critical care unit. The key lesson of our study is not only the specific findings obtained here but also how combining a case study approach with the ethical framework of "accountability for reasonableness" can be used to identify good practices and opportunities for improving the fairness of priority setting in intensive care.

Attitude of Health Personnel↗
PubMed2003

Ontario's formulary committee: how recommendations are made.

BACKGROUND: In 1996, the provincial government in Ontario, Canada required pharmaceutical manufacturers seeking to list their products on the provincial formulary to provide a formal economic analysis documenting the products' cost effectiveness. The provincial formulary lists pharmaceutical products for which reimbursement is provided for residents on the Ontario Drug Benefit Program (ODB). OBJECTIVE: To describe how listing decisions are made, and specifically the role of economic analysis in this process. DESIGN: A qualitative case study approach was taken. Data were analysed using the pattern-matching technique. Data consisted of meeting transcripts and interviews with committee members, which were coded and weighted for analysis using the pattern-matching technique. SETTING: Nine meetings of the Drug Quality and Therapeutics Committee (DQTC), which makes listing recommendations to the ODB, were observed. PARTICIPANTS: Seven individual committee members were interviewed. RESULTS: Complex economic analyses (i.e. analyses more involved than a simple cost-consequence analysis) played a limited role. The clinical factor dominated the perception of costs. Generic and 'me-too' products with no price premium did not require complex economic analyses. Poor quality analyses were not useful and the DQTC members' lack of in-depth knowledge of health economics influenced the extent to which analyses were discussed. The DQTC did discuss economic issues however, and often performed informal economic analyses to guide decisions. CONCLUSIONS: Complex economic analyses had an impact on provincial drug benefit decisions in a limited number of circumstances, principally for expensive innovative products. However, the committee did use some form of economic analysis to guide decisions in almost all cases, and therefore requesting economic analyses, even simple ones, from manufacturers seeking formulary listing is a useful healthcare policy.

Cost-Benefit Analysis↗