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PubMed1992

Ethical conflicts in the prehospital setting.

STUDY OBJECTIVE: To assess the range of ethical conflicts that confront prehospital care providers. DESIGN: Convenience sample, from October 1989 to January 1990. SETTING: An urban advanced life support emergency medical service that transports approximately 3,000 patients per month. METHODS: Six hundred seven paramedic responses were analyzed by a single observer. An ethical conflict was identified when the paramedic faced a dilemma about what "ought to be done" and the paramedic's values conflicted or potentially conflicted with the patient's. Cases with potential ethical consequence were brought to experts in medical ethics and epidemiology for further analysis and classification. RESULTS: Ethical conflicts arose in 14.4% of paramedic responses (88 of 607 cases). Twenty-seven percent of the conflicts involved issues of informed consent, such as refusal of treatment or transport, conflicts of hospital destination, treatment of minors, and consent for research. Difficulties regarding the duty of the paramedics, usually under threatening circumstances, accounted for 19% of the dilemmas encountered. Requests for limitation of resuscitation accounted for 14%. Other circumstances that presented ethical conflicts involved questions of patient competence (17%), resource allocation (10%), confidentiality (8%), truth telling (3%), and training (1%). CONCLUSION: The data demonstrate a range of ethical conflicts in the prehospital setting and point to areas in which policy needs to be developed. The data also can be used in a prehospital ethics curriculum for paramedics and physicians. Because case sampling was not strictly random, absolute conclusions should not be drawn regarding the frequency of the dilemmas.

Beneficence↗
PubMed2002

A survey of genetic counselors' strategies for addressing ethical and professional challenges in practice.

There is limited research about ethical and professional dilemmas that genetic counselors encounter in their practice and their strategies for addressing them. In this study, 454 genetic counselors rated the frequency with which they encounter each of 16 ethical/professional challenges identified and categorized previously (McCarthy Veach P., Bartels DM, LeRoy BS (2001) J Genet Couns 10(2):97-119). Over 40% indicated these issues occurred frequently: patient emotions, diversity, financial constraints, uncertainty, and colleague error. Two hundred and fifty-five respondents provided personal anecdotes describing exceptionally challenging situations and recommended strategies for addressing them. Most of their anecdotes involved informed consent, value conflicts, confidentiality, colleague error, withholding information, and resource allocation. The most frequently recommended strategies were further discussion with patients, consultation with other professionals, and referral to other health sources. Thirty-five respondents were unable to/did not offer strategies. Respondent demographics were not related to frequency of issues, type of anecdote, or recommended strategies. Practice, policy, and research implications are discussed.

Attitude of Health Personnel↗
PubMed1993

A model of the impact of immigration on health and social service expenditures for the elderly.

"Immigration, primarily from the former Soviet Union, has swelled the population of Israel by 10% between 1990 and 1993 and total population growth by the end of the decade is expected to be over 30%. The research presented here represents part of a larger effort to project needs and costs for the entire population in order to assist health and social welfare services in planning and resource allocation. The paper presents an overview of the current demographic situation in Israel, a theoretical model for estimating the growth in needs, and estimates of needs and costs for services for the elderly population based upon this model."

Asia↗
PubMed2006

Confronting an influenza pandemic: ethical and scientific issues.

The prolonged concern over the potential for a global influenza pandemic to cause perhaps many millions of fatalities is a chilling one. After the SARS (severe acute respiratory syndrome) scares [1], attention has turned towards the possibility of an avian influenza virus hybridizing with a human influenza virus to create a highly virulent, as yet unknown, killer, on a scale unseen since the Spanish flu outbreak of 1918, which produced more fatalities than the Great War. In deciding how countries should react to this potential pandemic, individually and collectively, a reasonable and practical balance must be struck between the rights and obligations of individual citizens and protection of the wider community and, indeed, society as a whole. In this communication, ethical issues are discussed in the context of some of the scientific questions relating to a potential influenza pandemic. Among these issues are the rights and obligations of healthcare professionals, difficulties surrounding resource allocation, policies that have an impact on liberty and trade, when and how to introduce any vaccine or other form of mass treatment, global governance questions and the role of health policies in contemporary society. By considering these issues and questions in advance of an influenza, or indeed any other, pandemic commencing, countries can be better prepared to deal with the inevitably difficult decisions required during such events, rather than dusting down outdated previous plans, or making and implementing policy in an ad hoc manner with a resultant higher risk of adverse consequences.

Disease Outbreaks↗
PubMed2006

Defining the clinical improvement in cancer drug therapy: implications for priority setting in healthcare.

An explicit approach to funding decisions has become increasingly important to ensure fairness and consistency in resource allocation in cancer therapy. Funding decisions are often based on whether a treatment is 'medically necessary' and the level of clinical improvement. Currently, there is a lack of consensus on defining different levels of clinical improvement, leading to controversies on the values placed on different outcomes and degrees of clinical improvements during funding evaluation. More information on how clinicians and patients define the levels of clinical improvement can help ensure the evaluation and decision-making processes of funding to become more predictable, consistent, understandable and therefore accountable to providers and consumers of healthcare.

Attitude of Health Personnel↗
PubMed2001

Ethical challenges in geriatrics and long-term care.

BACKGROUND: The Canadian population, like that of other western countries, is aging. OBJECTIVE: To review ethical issues related to clinical practice, research, and resource allocation in the geriatric and long-term care population. METHODS: Through the use of case histories and relevant literature review, we explore issues in geriatrics and long-term care. CONCLUSIONS: It is incumbent on health-care providers involved in geriatrics and long-term care to be sensitive to the ethical issues that surround decision-making in the later years of life. It is through this process that we can be humane professionals in a caring society.

Aged↗
PubMed2004

Strategies to control costs and quality: a focus on outcomes research for disease management.

Rapid adoption of disease management has outpaced systematic evaluation of its net value in improving health outcomes and mitigating healthcare cost. This article identifies areas in which outcomes research in disease management is needed to demonstrate its value or to enhance its performance. Patient identification for disease management relies on administrative database queries but the trade-offs in sensitivity, specificity, and predictive value of alternative queries are not well known. Large-scale deployment, rapid patient engagement, and repeated interactions between patients and nurses could be important attributes for attaining measurable improvements in quality and cost reduction over short periods of time, but these hypothesis need to be tested. There is a trend toward integration of multiple chronic disease management programs onto a single platform. To support this trend, there is a need for a corresponding set of integrated clinical guidelines or "meta-guidelines" that combine the contents of individual practice guidelines. The relative contribution of various disease management interventions in improving clinical results, lowering costs, and their respective ease of implementation is not known. Research leading to a better understanding of tradeoffs could lead to more rational resource allocation and better overall outcomes. Coordination between disease management programs and physician practices is lacking. Research aimed at defining operational and technical interfaces and cultural and behavioral professional adjustments necessary to achieve integration and coordination is needed. The lack of a consistent analytical framework for evaluating clinical and financial outcomes has made comparisons of reported results impossible and has rendered many reports unreliable. Theoretical work on a standard methodology that integrates clinical and financial outcomes and empiric validation is needed.

Aged↗
PubMed2006

Limiting and rationing treatment in paediatric and neonatal intensive care.

In this chapter I consider the ethical decisions surrounding the provision and limitation of treatment offered to children requiring intensive care. I focus on the processes surrounding end of life decision making and consider how the concepts of futility, burden and uncertainty should impact upon these decisions. I also examine resource allocation to children's critical care services. The discussion does not provide a structure that will solve any given situation. It does take a practical approach to the issues faced by considering why we should engage in life limiting discussions; When they should occur; Who should be involved; How they should be carried out; and where and by what means withholding or withdrawal should occur. I have drawn the discussions closer to clinical practice with the intention of making them more useful, for those engaged in direct patient care, than those focused around philosophical principles.

Adolescent↗
PubMed2006

An illustration of whole systems thinking.

The complexity of policy-making in the NHS is such that systemic, holistic thinking is needed if the current government's plans are to be realized. This paper describes systems thinking and illustrates its value in understanding the complexity of the diabetes National Service Framework (NSF); its role in identifying problems and barriers previously not predicted; and in reaching conclusions as to how it should be implemented. The approach adopted makes use of soft systems methodology (SSM) devised by Peter Checkland. This analysis reveals issues relating to human communication, information provision and resource allocation needing to be addressed. From this, desirable and feasible changes are explored as means of achieving a more effective NSF, examining possible changes from technical, organizational, economic and cultural perspectives. As well as testing current health policies and plans, SSM can be used to test the feasibility of new health policies. This is achieved by providing a greater understanding and appreciation of what is happening in the real world and how people work. Soft systems thinking is the best approach, given the complexity of health care. It is a flexible, cost-effective solution, which should be a prerequisite before any new health policy is launched.

Communication↗
PubMed1995

Conceptual and moral disputes about futile and useful treatments.

A series of cases have crystallized disputes about when medical treatments are useful or futile, and consequently about the doctor-patient relationship, resource allocation, communication, empathy, relief of suffering, autonomy, undertreatment, overtreatment, paternalism and palliative care. It is helpful to understand that utility and futility are complimentary concepts and that judgments about whether treatments are useful or futile in the contested cases have common features. They are: (1) grounded in medical science, (2) value laden, (3) at or near the threshold of utility, and (4) burdensome. No schema for line-drawing escapes borderline cases and we should focus upon justification of the empirical, ethical and evaluative components underlying these judgments, rather than make an arbitrary decision about whether doctors, patients or societal consensus should be the final arbiter.

Beneficence↗
PubMedDate not supplied

Pharmacoeconomics.

Pharmacoeconomics focuses on the costs and benefits of drug therapy and pharmacoeconomic evaluations provide a basis for resource allocation and utilization. It is increasingly becoming important for health policy decision-making. A pharmacoeconomic evaluation may be conducted as an economic assessment incorporated into clinical trials. Such trials should compare the new drug/procedure with an older drug or existing intervention. Four techniques are used for economic evaluation, namely, cost-minimization analysis, cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis. The choice of the evaluation method depends on the nature of outcomes and the context in which the choices need to be made. Pharmacoeconomics is a young science that will improve with application. Its need is undeniable, especially in developing countries.

Clinical Trials as Topic↗
PubMed2005

Access to trauma centers in the United States.

CONTEXT: Previous studies have reported that the number and distribution of trauma centers are uneven across states, suggesting large differences in access to trauma center care. OBJECTIVE: To estimate the proportion of US residents having access to trauma centers within 45 and 60 minutes. DESIGN AND SETTING: Cross-sectional study using data from 2 national databases as part of the Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH) project. Trauma centers, base helipads, and block group population were counted for all 50 states and the District of Columbia as of January 2005. MAIN OUTCOME MEASURES: Percentages of national, regional, and state populations having access to all 703 level I, II, and III trauma centers in the United States by either ground ambulance or helicopter within 45 and 60 minutes. RESULTS: An estimated 69.2% and 84.1% of all US residents had access to a level I or II trauma center within 45 and 60 minutes, respectively. The 46.7 million Americans who had no access within an hour lived mostly in rural areas, whereas the 42.8 million Americans who had access to 20 or more level I or II trauma centers within an hour lived mostly in urban areas. Within 45 and 60 minutes, respectively, 26.7% and 27.7% of US residents had access to level I or II trauma centers by helicopter only and 1.9% and 3.1% of US residents had access to level I or II centers only from trauma centers or base helipads outside their home states. CONCLUSION: Selecting trauma centers based on geographic need, appropriately locating medical helicopter bases, and establishing formal agreements for sharing trauma care resources across states should be considered to improve access to trauma care in the United States.

Air Ambulances↗
PubMed2006

Do community factors have a differential impact on the health outcomes of boys and girls? Evidence from rural Pakistan.

In countries with large gender disparities in health status, can investments in local communities mitigate the gender bias observed in intra-household resource allocations? This paper explores the evidence for gender differences in the impact of community prices and infrastructure on child nutritional outcomes. Standardized heights and weights of rural Pakistani children are used as health indicators, while community factors include wheat prices, availability of piped water, accessibility of shops and government health clinics and the quality of the closest health facilities. The results suggest that food subsidies and programmes designed to improve the access and quality of local services may reduce the impact of intra-household gender bias on child nutrition, particularly in the long run. Specifically, by increasing the affordability of staple foods, improving the access to shops and government health centres and enhancing the quality of local care, particularly (gender-neutral) prenatal care, gender gaps in health outcomes are likely to diminish.

Child↗
PubMed1997

Managed care: how economic incentive reforms went wrong.

In its response to pressures to rationalize health care resource allocation, the American health care system has embraced managed care without concurrent comprehensive health care reform, either in the form of the centralized tax-based systems found in Europe and Canada or that of the Clinton reform plan. What survives is managed care without managed competition, employer mandates, or universal access. Two problems inherent in the incentive structure of managed care plans developed in the absence of comprehensive health care reform work against the public interest. First, sacrifices in terms of medical innovation and quality of care may not be offset by greater equity in the distribution of health care. Second, such managed care plans fail to address the need for long-term accountability.

Biomedical Technology↗
PubMed1992

The untold story: how the health care systems in developing countries contribute to maternal mortality.

This article attempts to put together evidence from maternal mortality studies in developing countries of how an inadequate health care system characterized by misplaced priorities contributes to high maternal mortality rates. Inaccessibility of essential health information to the women most affected, and the physical as well as economic and sociocultural distance separating health services from the vast majority of women, are only part of the problem. Even when the woman reaches a health facility, there are a number of obstacles to her receiving adequate and appropriate care. These are a result of failures in the health services delivery system: the lack of minimal life-saving equipment at the first referral level; the lack of equipment, personnel, and know-how even in referral hospitals; and worst of all, faulty patient management. Prevention of maternal deaths requires fundamental changes not only in resource allocation, but in the very structures of health services delivery. These will have to be fought for as part of a wider struggle for equity and social justice.

Abortion, Legal↗
PubMed1995

The adequacy of medical ethics education in a pediatrics training program.

PURPOSE: To identify ethical dilemmas commonly encountered during pediatrics training as a step toward improving medical ethics curricula for residents. METHOD: The authors identified seven recurring topics by reviewing the required case reports on ethical dilemmas experienced by students in the third-year pediatrics clerkship from June 1992 to June 1994 at the State University of New York at Buffalo School of Medicine and Biomedical Sciences. Based on the topics identified, the authors then surveyed pediatrics housestaff in 1993-94 regarding the frequency of encountering the topics, levels of comfort in addressing the topics, role models and resources, and perceived need for improved training. RESULTS: A total of 214 student essays were reviewed. Thirty-six of 50 residents responded to the survey. In the following list of the seven topics, percentages are given for students who reported the topic, for residents who encountered the topic "very frequently" or "sometimes," and for residents who felt "very comfortable" or "somewhat comfortable" addressing the topic: child abuse or neglect (students reported, 28%, residents encountered, 94%, residents felt comfortable, 86%); use of heroic measures to maintain a terminal patient (20%, 89%, 69%); patient confidentiality (19%, 81%, 92%); resource allocation (12%, 67%, 54%); surrogate decision making (7%, 69%, 75%); patient autonomy (4%, 86%, 69%); and disclosure of information (2%, 69%, 60%). Eighty percent of the residents felt they could not intervene when they disagreed with decisions; 69% felt their training had not prepared them to address ethical dilemmas; 69% thought attending physicians were interested in discussing ethical issues; and 74% desired more training. CONCLUSION: Based on their self-reported experiences with topics identified as occurring frequently in pediatrics training, the residents perceived their training to be inadequate and desired more ethics education, but felt that the faculty were willing to assist in that training.

Adolescent↗
PubMed2004

What can rural agencies do to address the additional costs of rural services? A typology of rural service innovation.

There is a national commitment to ensuring that, regardless of where patients live, they should be provided with an acceptable level of service in terms of quality, effectiveness and accessibility. Because of differences in the distributions of their populations, rural and urban areas present quite different challenges for the optimal design of health services and social care. However, this has not been fully acknowledged in the development of national policies to unify service standards. The problems of providing services in sparsely populated areas are not new. However, until the case for a rural premium in English health resource allocation is accepted, rural agencies must either tolerate lower levels of services (an option made difficult by the introduction of national service standards) or develop very different approaches to service delivery. To date, there has been little systematic knowledge about the extent of innovative rural practice, a paucity of evaluation of such initiatives and few opportunities to disseminate learning from one area to another. The present paper begins to address this deficit. Drawing upon a review of the formal literature and a comprehensive evaluation of projects developed within a rural Health Action Zone, it presents a typology of innovative responses at the health/social care interface. Examples of service innovations which fall into six broad categories are provided. These not only suggest possibilities for the transfer of good practice, but also the potential for future research.

Diffusion of Innovation↗
PubMed1995

What do ethics have to do with lifestyle change?

The discussions around health and health care suggest that many of the diseases prevalent in our society today are a direct result of lifestyle choices made by citizens. As these discussions continue, there is mounting evidence relating personal habits and lifestyle to major causes of mortality and morbidity. This evidence, coupled with the technological advances in health care and the resource allocation issues around health care delivery, is leading to a plethora of ethical concerns, questions and challenges. There has been little movement in society to begin to address these issues, although there is growing recognition that to solve these dilemmas a collaborative partnership of providers and consumers is required. In this paper, selected ethical issues associated with lifestyle and behaviour change are explored, with emphasis on the dilemmas that may occur as a result of differences in values. Various conceptual approaches to the issue of 'voluntariness' and several models for examining whether or not health risks are voluntary will be reviewed briefly. The use of interdisciplinary ethical decision making, and ongoing consumer and health care provider collaboration and dialogue, are emphasized as a means of beginning to solve these dilemmas.

Canada↗