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PubMed1995

Creating a dignified option: ethical considerations in the formulation of prehospital DNR protocol.

Increasing numbers of states are recognizing the importance of developing policies to allow Do Not Resuscitate (DNR) orders to be recognized in the prehospital setting, especially by emergency medical personnel. The ethical issues involved in creating such policies have not been widely addressed. Using the experience of developing such a policy for the District of Columbia as a model, we discuss six major ethical issues involved in prehospital DNR order policy development. 1) Can the justification for the policy be grounded in the doctor's duty of beneficence? 2) Should the concept of futility be applied to prehospital DNR orders? 3) How specific should prehospital DNR orders be? 4) How can one maximize patient participation in the prehospital DNR decision? 5) How much consideration ought to be given to the scarcity of health care resources in the development and justification of such policies? 6) Should paramedics be empowered to pronounce DNR patients dead in the field? This discussion ought to be of benefit to all those involved in developing or revising prehospital DNR policies.

Advisory Committees↗
PubMed2005

Prescribing eyeglass correction for astigmatism in infancy and early childhood: a survey of AAPOS members.

PURPOSE: To determine prescribing practices of pediatric ophthalmologists for astigmatism and astigmatic anisometropia in infants and young children. METHODS: A survey was sent to the 700 North American AAPOS members listed in the 2004 web site directory. RESULTS: A total of 412/700 surveys (59%) were returned. The level of astigmatism at which pediatric ophthalmologists prescribe eyeglasses for astigmatism varies considerably across the age range from birth to 3 years. The level at which 50% would prescribe glasses was > or =4.00 D from 0 to <6 months and decreased to > or =2.00 D by 2 to <3 years. Furthermore, one-fifth indicated that they would not prescribe eyeglasses for astigmatism in infants <6 months of age. Prescribing practices for astigmatic anisometropia were slightly less variable across age, with 50% of respondents indicating that they would prescribe eyeglasses for astigmatic anisometropia > or =3.00 D from 0 to <6 months, decreasing to > or =1.50 D by 2 to <3 years. CONCLUSIONS: The American Academy of Ophthalmology Preferred Practice Patterns guidelines accurately reflect prescribing practices of pediatric ophthalmologists for 1- and 2-year-old children for bilateral astigmatism and astigmatic anisometropia. However, the AAO guidelines do not accurately reflect the prescribing practices for children in the 0 to <1-year age range. For children 0 to <6 months of age, pediatric ophthalmologists indicate that they typically require a higher amount of astigmatism or astigmatic anisometropia than that recommended by the AAO guidelines, or they do not prescribe glasses at all.

Academies and Institutes↗
PubMed2006

From passive subject to active agent: the potential of Citizens' Juries for nursing research.

The nursing profession needs to have a greater appreciation of how techniques such as Citizens' Juries can be used in nursing research. This paper explains the concept of Citizens' Juries and how it is being used as a form of social research, that can simultaneously increase public participation in policy making. Participation has become a key component of the discourse in policy making, and public participation initiatives can be one way of bridging the democratic deficit. For nursing, Citizens' Juries offer a way of discovering lay people's considered judgment on key policy issues, while also providing a potentially powerful platform for citizens to express their concerns and priorities, thereby influencing the services they receive. A Citizens' Jury brings together a small group of people over a period of time and presents them with a policy question. The jurors listen to expert witnesses, examine the evidence, deliberate on the issues and arrive at a policy decision or set of recommendations. In this paper we argue that any ordinary person given the opportunity, enough time and the necessary resources can make decisions about complex policy matters. Key findings from two Citizens' Juries on genetics in Wales are offered as case studies.

Committee Membership↗
PubMed2003

The use of 'arms-length' organizations for health system change in Ontario, Canada: some observations by insiders.

During the past decade, there has been substantial health system reform in the United States, United Kingdom, New Zealand, and many other countries. For the most part, Canada has not pursued 'big bang' health system change but rather a variety of strategies to achieve incremental change. In this paper, we present the ways in which three arms-length organizations have been used by government to effect incremental system change in Ontario during the past several years. We observe that, (1) the influence of politics and political interference can be reduced through an arms-length organization; (2) an arms-length organization with the power to make decisions entails more political risk for government and encounters more scrutiny and criticism by providers and the media than an organization with the power to recommend only; (3) an arms-length organization with a limited lifespan faces more delaying tactics by adversely affected parties than an organization without a limited lifespan; (4) an arms-length organization with perceived influence may attract causes that are not related to its mandate; (5) the importance and difficulty of communicating complex information about system change to a wide variety of audiences cannot be overstated; (6) system change informed by the use of expert opinion encounters less provider resistance and may result in better decisions; and (7) the reputation of the Chair and the perceived competence and experience of the CEO are critical success factors in the success of an arms-length organization.

Cardiac Care Facilities↗
PubMed2000

Using the Baldrige management system framework in health care: the Veterans Health Administration experience.

BACKGROUND: In 1998 the Veterans Health Administration (VHA) developed the Quality Achievement Recognition Grant, a competitive grant application open to all Veterans Integrated Service Networks (VISNs) within the VHA system and based on the Baldrige management framework. Eight of the 22 VISNs attended the educational programs and initiated the grant application process; 7 completed applications. Team award experts from VHA and external sources reviewed, scored, and wrote feedback reports to all applicants and conducted four site visits. IDENTIFICATION OF BEST PRACTICES AND RECOMMENDATIONS FOR FUTURE APPLICANTS: Each application was compared to examples of ideal applications to identify areas of excellence and areas for improvement. In general, the best applicants identified and described key processes and articulated the methods used to evaluate and improve processes. For example, they were able to identify the process used to incorporate key constituents into the strategy development process. One applicant developed a series of management advisory committees, the membership of which includes veterans' service organizations, academic affiliates, community members, and congressional delegates, which were tapped to develop a strategic plan. Leading applicants in the future are likely to be able to demonstrate evidence of deployment and constant review of the strategy and to emphasize the human resources plan into the strategic planning and deployment. CONCLUSIONS: The Baldrige management framework is a useful tool for identification of areas of achievement and areas for improvement within the VHA. Potential applicants for the award could benefit from ensuring coherence across the application, placing a greater emphasis on work systems, and incorporating more extensive analysis of market conditions.

Awards and Prizes↗
PubMed2001

Regulating reproduction: the art of decision-making in ART.

Fertility treatment in the UK takes place within a strict regulatory framework that represents the outcome of legislative decisions aimed at protecting the interests of both patients and the public, whilst maximizing the acceptable reproductive options available to them. The role and responsibilities of the Human Fertilisation and Embryology Authority are described and illustrated in the context of the complementary domains of the lawmakers on the one hand and clinicians on the other. The constitution of the HFEA - its multidisciplinary membership, internal committee structure and the function of its officers - is characterized as a mechanism that ensures that relevant perspectives inform its decision-making whilst guarding against the charge of partiality. Through the Code of Practice it produces and the licensing system it operates, the HFEA both protects and supports good clinical decision-making within the ART community.

Journal Article↗
PubMed1999

Expectations and outcomes in organ transplantation.

Research is needed on the frequency of bad outcomes in transplantation. Allocation policies and professional or institutional self-interest may affect the incidence of bad outcomes, and the need for reform is stressed. Transplant recipients who have had a bad outcome often continue to receive aggressive care. The humanistic care of patients having bad outcomes requires attention to advance directives, discussion with patient and family of alternatives to aggressive treatment, and provision of an option for home hospice care. Finally, it must be reemphasized that the average typical good outcome is extraordinarily good, restoring function of a vital organ, extending and improving quality of life, and sometimes restoring near-normal health. In no way should the fact of bad outcomes reduce our commitment to producing good outcomes.

Committee Membership↗