By-Person Factor Analysis in Clinical Ethical Decision Making: Q Methodology in End-of-Life Care Decisions

Objective: To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues.

Design: Qualitative study using by-person factor analysis of subjective Q sort data matrix.

Setting: University medical center.

Participants: Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center.

Interventions: Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases.

Measurements and Main Results: Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r ² < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study.

Conclusions: Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants' decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies.     

医疗决策的程序公正

由于社会满足不了所有的医疗需求,医疗决策问题变成了确定医疗的限度问题。由于社会对于限度决定很难获得共识,医疗决策要通过公正的程序获得。医疗决策不能由某个人或某个团体或权力机构做出,而应该通过民主协商来做出,否则,人们会质疑医疗决策的合法性。     

医疗决策的程序公正

由于社会满足不了所有的医疗需求,医疗决策问题变成了确定医疗的限度问题.由于社会对于限度决定很难获得共识,医疗决策要通过公正的程序获得.医疗决策不能由某个人或某个团体或权力机构做出,而应该通过民主协商来做出.否则,人们会质疑医疗决策的合法性.     

Religious,Ethical and Legal Considerations in End-of-Life Issues: Fundamental Requisites for Medical Decision Making

Religion and spirituality have always played a major and intervening role in a person’s life and health matters. With the influential development of patient autonomy and the right to self-determination, a patient’s religious affiliation constitutes a key component in medical decision making. This is particularly pertinent in issues involving end-of-life decisions such as withdrawing and withholding treatment, medical futility, nutritional feeding and do-not-resuscitate orders. These issues affect not only the patient’s values and beliefs, but also the family unit and members of the medical profession. The law also plays an intervening role in resolving conflicts between the sanctity of life and quality of life that are very much pronounced in this aspect of healthcare. Thus, the medical profession in dealing with the inherent ethical and legal dilemmas needs to be sensitive not only to patients’ varying religious beliefs and cultural values, but also to the developing legal and ethical standards as well. There is a need for the medical profession to be guided on the ethical obligations, legal demands and religious expectations prior to handling difficult end-of-life decisions. The development of comprehensive ethical codes in congruence with developing legal standards may offer clear guidance to the medical profession in making sound medical decisions.     

国外临床决策研究进展（上）

2004年～2010年国际医学决策学会年会,提出许多与临床相关的决策问题,其中包括健康经济学与成本效益分析,临床方法学研究进展,医患双方的临床决策选择,公共卫生服务研究和诊疗策略的关系,临床策略与治疗指南,高新技术与适宜技术等。本文就以上问题,尤其是临床决策研究热点,对国外临床决策研究进展进行总结、探讨和评价,为临床应...     

重视临床决策,提高临床医学水平

当代临床医学的发展与提高,与基础医学的研究密切相关,与科学技术提供的诊疗装备密切相关.由于现代信息技术的发展迅速,科技情报传递速度很快,以及经济全球化提供的便利快速的物流网络,医学的任何新设备、新药物、新的诊疗方法问世后,很快就能传遍全世界.就我国而言,我国临床医学水平与一些国家的差距,主要不是装备的差距,不是新设备、新药物的差距,而是如何运用医学新技术、新设备、新药物的差距,实际上也就是临床研究思维和临床决策水平的差距.     

Combining Patient Utility with Health Status Assessment to Improve Medical Decision Making

Physicians often use health status assessment tools to evaluate a patient's condition, then apply established guidelines to determine the most medically effective treatment. Yet additional criteria, such as the appropriateness of the treatment given the particular patient's preferences and attitude toward risk, are also highly relevant to quality care. While such preferences could be addressed via patient utility functions, their use in actual practice is somewhat limited because elicitation is often considered too burdensome for patients, unreliable, or redundant given other measures. For a small group of real patients who have suffered a stroke, we measure both traditional health status and patient utility for the current state to determine whether limited, focused utility assessment is a practical means of obtaining additional and relevant patient information. We find that utility assessment is perceived as reasonable and useful by patients, even when quite ill, and that utilities and health status are not redundant. In fact, investigating apparent inconsistencies between patient utility and observed health status can alert the physician to patient concerns and criteria not captured by more traditional measures. We propose an approach to medical decision making that uses both measures to improve patient–physician communication.     

Aligning Islamic Spirituality to Medical Imaging

This paper attempts to conceptualize Islamic spirituality in medical imaging that deals with the humanistic and technical dimensions. It begins with establishing an understanding concerning spirituality, an area that now accepted as part of patient-centred care. This is followed by discussions pertaining to Islamic spirituality, related to the practitioner, patient care and the practice. Possible avenues towards applying Islamic spirituality in medical imaging are proposed. It is hoped that the resultant harmonization between Islamic spirituality and the practice will trigger awareness and interests pertaining to the role of a Muslim practitioner in advocating and enhancing Islamic spirituality.     

The Default Position: Optimizing Pediatric Participation in Medical Decision Making

Inclusion of children in medical decision making, to the extent of their ability and interest in doing so, should be the default position, ensuring that children are routinely given a voice. However, optimizing the involvement of children in their health care decisions remains challenging for clinicians. Missing from the literature is a stepwise approach to assessing when and how a child should be included in medical decision making. We propose a systematic approach for doing so, and we apply this approach in a discussion of two challenging clinical cases. The approach is informed by a literature review, and is anchored by case studies of teenagers' refusal of clinical care, regulatory requirements for research assent, and the accepted approach to involving cognitively impaired adults in medical decisions.     

重症医学科医生哲学素养与临床决策

随着我国重症医学的飞速发展,,临床医生面临着复杂病情诊治思维的困惑、人文与伦理的掺杂、医疗技术的"双刃剑"效应、医患沟通、团队合作等一系列问题挑战.因此,重症医学科医生必须丰富自己的哲学素养、从中国传统哲学及"天人合一"思想中汲取智慧精华,才能运用正确的理论思维更好地指导临床决策.     

泌尿外科微创技术与临床决策

微创技术在泌尿外科中的应用越来越广泛,对临床决策也产生了深远的影响。临床决策应以最佳证据作指导,充分评价不同方案的风险和利益,选择出最优方案应用于临床实践。微创技术的应用要以人为本,要贯穿诊断和治疗的全过程,要因地制宜,充分考虑应用的物质条件和基础。微创技术的应用也必须考虑经济因素,应选择适宜技术进行适度治疗。     

泌尿外科微创技术与临床决策

微创技术在泌尿外科中的应用越来越广泛,对临床决策也产生了深远的影响.临床决策应以最佳证据作指导,充分评价不同方案的风险和利益,选择出最优方案应用于临床实践.微创技术的应用要以人为本,要贯穿诊断和治疗的全过程,要因地制宜,充分考虑应用的物质条件和基础.微创技术的应用也必须考虑经济因素,应选择适宜技术进行适度治疗.     

Decision Development in Computer-Assisted Group Decision Making

New computer technologies to aid group communication and decision making are becoming increasingly widespread. This study analyzes how one such technology, a group decision support system (GDSS), affected how group decisions developed over time. The study contrasted decision paths in groups using the GDSS with groups using the same procedural structures incorporated in the GDSS manually and with groups using no procedural structures. A flexible phase mapping method was employed to map group decision paths. The resulting set of seven decision paths varied in both sequence and number of decision phases. An optimal matching procedure was used to compute similarity measures among the 40 paths, and cluster analysis and multidimensional scaling were used to generate an empirical taxonomy of decision paths. Results indicated that the nature of decision paths varied both across the three conditions and within conditions. The decision path types were also related to three outcome variables: consensus change, perceived decision quality, and decision scheme satisfaction. Results indicated that those decision paths that most resembled logical normative sequences had superior outcomes to those that did not.