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PubMed2000

[Recognizing the situation (1): a plea for an open debate about rationing].

The rise in health costs is due to the tremendous advances in medical science and other causes, such as a system offering a unique financial stimulus for health professionals to provide more services, non-functioning competition, patients' demand for every possible form of treatment as rapidly as possible, a compliant political community and also new players such as consultants, the ethics industry, lawyers and nursing academics. On the other hand, the public is not willing to pay more in taxes and health insurance premiums. The resultant dilemma sooner or later forces restrictions on health care which can be called either optimisation, rationalisation or rationing.

Health Care Rationing↗
PubMed2001

Guidelines as rationing tools: a qualitative analysis of psychosocial patient selection criteria for cardiac procedures.

BACKGROUND: Cardiac procedure guidelines often include psychosocial criteria for selecting patients that potentially introduce social value judgements into clinical decisions and decisions about the rationing of care. The aim of this study was to investigate the terms and justifications for and the meanings of psychosocial patient characteristics used in cardiac procedure guidelines. METHODS: We selected English-language guidelines published since 1990 and chapters in textbooks published since 1989. These guidelines amalgamated multiple sources of evidence and expertise and made recommendations regarding patient selection for specific procedures. A multidisciplinary team of physicians and social scientists extracted passages regarding psychosocial criteria and developed categories and conceptual relationships to describe and interpret their content. RESULTS: Sixty-five papers met the criteria for inclusion in the study. Forty-five (69%) mentioned psychosocial criteria as procedure indications or contraindications. The latter fell into several categories, including behavioural and psychological issues, relationships with significant others, financial resources, social roles and environmental circumstances. INTERPRETATION: Psychosocial characteristics are portrayed as having 2 roles in patient selection: as risk factors intrinsic to the candidate or as indicators of need for special intervention. Guidelines typically simply list psychosocial contraindications without clarifying their specific nature or providing any justification for their use. Psychosocial considerations can help in the evaluation of patients for cardiac procedures, but they become ethically controversial when used to restrict access. The use of psychosocial indications and contraindications could be improved by more precise descriptions of the psychosocial problem at issue, explanations regarding why the criterion matters and justification of the characteristic using a biological rationale or research evidence.

Attitude of Health Personnel↗
PubMed2002

Breast augmentation should be on the NHS: a discussion of the ethics of rationing.

Every NHS clinician is under constant pressure to match limited resources to increasing demands. The GMC provides guidelines about how we should ration: 'you should always seek to give priority to the treatment of patients solely on the basis of clinical need'. However, this gives no indication as to what is 'need'. Often, in its application, certain assumptions are made about the nature of clinical need. To examine some of these assumptions in more detail, I will argue the case for a treatment that is on the borderline of the remit of NHS care--breast augmentation.

Ethics, Medical↗
PubMed2002

[Rational-emotive therapy in psychogeriatrics: a new application? Case report of a patient in daycare].

Literature indicates that the use of psychotherapeutic techniques in affective problems in patients with cognitive impairment is scarce and often considered to be ineffective. The feasibility of an individual treatment with Rational Emotive Therapy of a psychogeriatric patient was explored. The patient was diagnosed with moderate cognitive impairment, a depressive episode and generalised anxiety disorder. Simplification of the RET principles and integration in an interdisciplinary system were introduced as adjustments in the method. The treatment resulted in a reduction of depressive and anxiety complaints. Treatment limitations and patient variables which seemed to have contributed to the treatment success and which may have predictive value are discussed.

Aged↗
PubMedDate not supplied

Managed care organizations and the rationing problem.

By and large, neither bioethicists nor economists have offered a satisfactory account of how managed care organizations should ration health care. Both disciplines would like to guarantee adequate care to all without defining adequacy. But it cannot be done. The more we rely on market forces to distribute health care, the more we need a national standard of care.

Bioethics↗
PubMed2000

Ageism helps to ration medical treatment.

The world's population is ageing and this will have inevitable consequences for the demands on acute and longer term health care resources. Old age is rarely characterised by positive images and older age stereotypes are often unflattering and ugly. Many older people experience social exclusion as a result of low income, poor housing, little family support, isolation, disability and illness. Ageism is a prejudice which is invoked to deny older people the things they seek and ageism in medicine probably reflects ageism in society as a whole. Old age is a criterion for rationing health care resources and it occurs at all levels in the National Health Service. Older subjects are often excluded from research trials, have their surgical operations cancelled too often and are less often accepted for cardiological investigation and intervention. Women over 65 are not routinely invited for breast cancer screening and, once they are diagnosed, they may not be offered the same treatment as younger women. Ageism in clinical practice should be combated by better education of healthcare workers and treatment decisions should only be taken on an individual basis and not on stereotypical views. 'Age, I do abhor thee, Youth, I do adore thee.' Shakespeare, The Passionate Pilgrim.

Aged↗
PubMed1992

Audit of prioritisation for coronary revascularisation procedures: implications for rationing.

OBJECTIVE: to audit prioritisation of patients awaiting coronary revascularisation. DESIGN: the case records of 92 Christchurch patients referred for coronary artery bypass surgery (CABG) or percutaneous transluminal angioplasty (PTCA) from January to April 1990 were reviewed. The actual waiting time was compared with a nominally optimal waiting time, determined from an urgency rating score based primarily on severity of angina and coronary anatomy. RESULTS: of 56 patients referred for CABG, 47 had left main or multivessel disease including proximal stenosis of the left anterior descending artery. Fifty had Canadian class III or IV angina and 18 had impaired left ventricular function. At the time of review (January 1991), 16 had not yet had an operation. The mean waiting time was at least 163 (SD 116) days. Only nine (16%) had CABG within the maximum optimal time. Thirty-six patients had PTCA within eight months, mean waiting time 80 (53) days. These patients had less severe disease, but similar severity of angina. Nineteen (53%) had their procedure within the optimal period. CONCLUSION: waiting times for coronary revascularisation are excessive, even for high risk patients. Prospective monitoring of the waiting list using a standardised urgency rating score is likely to provide useful information on the dynamics of the waiting list for coronary revascularisation. Furthermore, the effects of further rationing of services can be analysed.

Aged↗
PubMed1991

The problems of the rational use of the medical staff in industrial health care complexes.

The awareness of resources scarcity in the occupational health care makes one analyze allocation in the selected institutions of occupational health service in Poland. The principal issue was to find out the differentiation in medical staff use and the costs involved. Such conclusions resulting from inputs and outputs evaluation are expected to be a basis for economic rationalization of resources allocation. An attempt to make such analysis has been made in Industrial Health Care Complexes (IHCCs) in Poland. Mainly, the costs of work of medical staff have been considered as an element of wider empirical study and comprehensive analysis of resources usage.

Cost Control↗
PubMed1991

Rationing health care resources: who will set limits?

Hospitals faced with additional reductions in Medicare and Medicaid reimbursements are discontinuing unprofitable services and programs. Nurses and physicians are finding that the patient's care plan is often dictated by economic considerations rather than what they believe to be beneficial. This article provides an overview of the problems and considerations involved in the rationing of health care resources.

Adult↗
PubMed1991

Age-based rationing of health care: a descriptive study of professional attitudes.

A national search for actual attitudes toward age-based rationing of health care among professionals in positions to support or change medical policies revealed that support for, or opposition to, medical limits for the elderly depended less upon affiliation, demographic factors, and political-economic ideology than did the sub-issues related to the rapid expansion of medical technology and spiraling health care costs in an unprepared society. The consensus was that American health care standards should continue to protect Granny Doe as well as Baby Doe.

Age Factors↗
PubMed1977

[Several aspects of the psychotherapy of neuroses (value of so-called rational psychotherapy)].

The authors consider neurosis as a disturbed ability of an adequate perception and reaction which must be corrected by the use of psychotherapy. The method of the socalled rational deep psychotherapy is taken as the main therapeutical influence. Other methods and measures are used in the complex with this method. The possibility of a patient's logical judgement in the use of the methods of suggestive therapy is pointed out. The new methods of psychotherapeutical influence are stated.

Autogenic Training↗
PubMed1995

Rationing trauma care to the elderly: an ethical dilemma.

It is estimated that by 2025, 25% to 35% of the people in this country will be older than 65 years. One of the hazards facing the elderly is the risk of trauma. Currently, one third of the total resources spent on trauma care are expended on the elderly, and this number will increase as the elderly segment of the U.S. population continues to grow. Despite aggressive care, the elderly trauma patient's chances of a good outcome are slim. However, is it ethical to ration trauma care on the basis of age? A case study of an elderly trauma patient provides an opportunity to apply an ethical decision-making model to the question.

Age Factors↗
PubMed1993

Informed consent to rationing decisions.

The prevailing legal and ethical opinion that rationing decisions must always be disclosed to patients is countered. Although conventional informed consent law could theoretically extend to decisions to decline treatment because of costs, it has not yet done so. Moreover, abandonment law does not prohibit declining treatment for economic reasons. A new theory of economic informed consent would stipulate that when patients make informed decisions to purchase less expensive health insurance, they are consenting in advance either to limiting marginally beneficial treatment or to waiving their right to be informed of particular decisions not to treat. Whether this will prove workable or will be accepted by the courts depends on the specifics of the enrollment disclosures, the range of choices given to subscribers, and their capacity to understand them.

Choice Behavior↗
PubMedDate not supplied

Widening the rationing debate.

This paper examines the financial background to the health-care rationing debate. The author draws attention to previous attempts to introduce resource allocation schemes and audit procedures into the NHS, and how some of the findings these systems have generated have been translated into health and social policy.

Delivery of Health Care↗
PubMed1994

The rationing of intensive care.

Meeting the challenges of allocating critical care resources in the fairest way possible depends upon the development of a standardized strategy for apportioning ICU services in times of limited supply. Two main approaches are emerging to handle these challenges. The first, rationing, requires the development of specific guidelines for determining ICU admission and discharge policies. The second approach involves improving the efficiencies of the care giving system itself. Either approach requires the establishment of a standard of care that reduces the potential for personal biases into the decision making process.

Age Factors↗
PubMed1996

Rationing: a transatlantic perspective.

Despite the differing mechanisms of health care delivery and financing in the United Kingdom and the United States many of the issues faced by the two countries are similar, most notably the increasing financial pressures. In both countries there have been recent changes in the allocation of resources and the mechanisms of decision making. Different criteria for determining resource allocation have been tried in the two health care systems. These developments change long traditions of rationing decisions at the individual patient level in the US, and of centralised government decision making in the UK.

Health Care Rationing↗
PubMed1989

The rational management of idiopathic intracranial hypertension.

Idiopathic intracranial hypertension is a diagnosis most frequently made in young, overweight women. The chief hazard to the patient is permanent visual loss due to chronic papilledema. After the diagnosis has been clearly established using lumbar puncture and imaging techniques, the neurologist is involved in helping to lower the intracranial pressure, control the headaches, and encourage weight loss. Careful vision monitoring is essential and should be done in collaboration with an ophthalmologist. Visual fields, fundus photographs, intraocular pressure measurement, and visual acuity should be performed at each follow-up visit. The use of visual evoked response and repeated measurement of intracranial pressure by lumbar puncture do not provide data that help to guide therapeutic decisions. Indications for surgery are loss of visual field or decline in visual acuity in the fact of medical therapy, persistent headache, or the inability to perform visual-function studies. Optic nerve sheath fenestration and lumbar peritoneal shunt both appear to be effective surgical means to reduce the pressure on the optic disc. A neurologist and an ophthalmologist working together provide the evidence on which to base rational decisions in the care of the patient with idiopathic intracranial hypertension.

Female↗
PubMed1994

Neuropsychological characterization of the AIDS dementia complex and rationalization of a test battery.

OBJECTIVE: To define the neuropsychological deficits present in mild human immunodeficiency virus type 1 (HIV-1) associated with the acquired immunodeficiency syndrome (AIDS) dementia complex (ADC) and to develop a rational neuropsychological test battery for its diagnosis. DESIGN: Survey. SETTING: Subjects were recruited from large metropolitan hospital outpatient clinics and were all living independently in the general community. PATIENTS: Three volunteer samples of homosexual-bisexual men: (1) 15 patients who met clinical and research criteria for mild ADC; (2) 27 HIV-seronegative (HIV-) controls; and (3) 17 patients with AIDS who were neurologically intact (NI-AIDS) who were matched with the ADC subjects by CD4 lymphocyte counts for severity of systemic HIV disease. MAIN OUTCOME MEASURES: Neuropsychological test performance; z score comparisons were made with the HIV-control group using 2.25-SD cutoffs for abnormality. RESULTS: Compared with NI-AIDS subjects, performance of patients with mild ADC was markedly worse in the cognitive areas of executive function, memory, and complex attention but not in affect or the cognitive areas of simple motor function, orientation, language, or visuospatial construction. Within the areas of executive function, memory, and complex attention, all of the HIV-controls and 95% of the NI-AIDS subjects had impaired test performance in a maximum of one area only. In marked contrast, 14 (93%) of the 15 patients with mild ADC had abnormal test performances in all three of these cognitive areas. Using a criterion of abnormal performance in at least two of the cognitive areas of executive function, memory, and complex attention, all patients with mild ADC could be differentiated from HIV-controls with 100% sensitivity and specificity and from NI-AIDS subjects matched for disease severity by CD4 lymphocyte count with 100% sensitivity and 94% specificity, which increased to 100% with the requirement of impairment in all three cognitive areas. CONCLUSIONS: If time constraints or patient compliance limit neuropsychometric testing, examination to detect mild ADC first should be directed to the areas of executive function, memory, and complex attention. This pattern of neuropsychological deficits in patients with mild ADC is suggestive of subcortical dementia.

AIDS Dementia Complex↗