Clinical decision making in the care of the aged

Which body functions and activities matter for stroke patients? Study protocol for best-Worst scalings to value core elements of the International Classification of Functioning, Disability and Health

BACKGROUND

Stroke is a common, serious, and disabling healthcare problem with increasing incidence and prevalence. Following a stroke, identifying the factors associated with decisions about rehabilitation interventions is important to assess rehabilitation after stroke. The aim is to guide clinical staff to make patient-centered decisions. Fundamentally, decision makers cannot draw on evidence to consider the relevance of distinct functions and activities from the patient's perspective. Until now, outcomes of rehabilitation are generally categorized using the International Classification of Functioning, Disability and Health (ICF). This can be seen as a conceptual basis for the assessment of health and disability. Since the ICF does not distinguish importance between these aspects there is a need to value the most important clinical factors as well as related activities from a patients and public perspective to help guide therapists in effectively designing post-acute rehabilitation care for individuals following stroke. The research question is which ICF body functions and activities are of value to stroke patients? Which trade-offs are patients willing to make within the core elements? Health preference research (HPR) answers the need to develop additional preference weights for certain ICF dimensions. Patient preference information (PPI) values health conditions based on the ICF from a patient perspective.

METHODS

In this study we conduct three best-worst scaling (BWS) experiments to value body function and activities from patients' and public perspective. Out of all ICF dimensions this research covers health conditions relevant to stroke patients in terms of body function, perception, and activities of daily living. Stroke patients as well as members of the general population will be recruited to participate in the online BWS surveys. Fractional, efficient designs are applied regarding the survey design. Conditional and multinominal logit analyses will be used as the main analysis method, with the best-worst count analysis as a secondary analysis. The survey is being piloted prior to commencing the process of data collection. Results are expected by the autumn of 2023.

DISCUSSION

The research will add to the current literature on clinical decision-making in stroke rehabilitation and the value of certain body functions as well as related activities in neurorehabilitation. Moreover, the study will show whether body functions and activities that are currently equally weighted in international guidelines are also equally important from the point of view of those affected, or whether there are disconcordances in terms of differences between public judgements and patients' preferences.

Most Important Factors for Deciding Rehabilitation Provision for Severe Stroke Survivors Post Hospital Discharge: A Study Protocol for a Best-Worst Scaling Experiment

Efficient decision-making is crucial to ensure adequate rehabilitation with optimal use of healthcare resources. Establishing the factors associated with making decisions concerning rehabilitation provision is important to guide clinical staff towards person-centred decisions for rehabilitation after severe stroke. In this study we conduct a best–worst scaling (BWS) experiment to identify the most important factors and their relative weight of importance for deciding the type of ongoing rehabilitation services a person with severe stroke might receive post hospital discharge. Fractional, efficient designs are applied regarding the survey design. Key multidisciplinary staff regularly involved in making decisions for rehabilitation in a stroke unit will be recruited to participate in an online BWS survey. Hierarchical Bayes estimation will be used as the main analysis method, with the best–worst count analysis as a secondary analysis. The survey is currently being piloted prior to commencing the process of data collection. Results are expected by the end of September 2021. The research will add to the current literature on clinical decision-making in stroke rehabilitation. Findings will quantify the preferences of factors among key multi-disciplinary clinicians working in stroke units in the UK, involved in decision-making concerning rehabilitation after stroke.

U.K. Intensivists' Preferences for Patient Admission to ICU: Evidence From a Choice Experiment

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Deciding whether to admit a patient to the ICU requires considering several clinical and nonclinical factors. Studies have investigated factors associated with the decision but have not explored the relative importance of different factors, nor the interaction between factors on decision-making. We examined how ICU consultants prioritize specific factors when deciding whether to admit a patient to ICU.

Developing an intervention around referral and admissions to intensive care: a mixed-methods study

Background

Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

Objectives

To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

Methods

A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.

Results

Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

Limitations

Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.

Conclusions

Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.

Future work

Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.

Study registration

The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.

Funding

The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

How people with dementia and carers understand and react to social functioning changes in mild dementia: a UK-based qualitative study

OBJECTIVES

To analyse people with dementia and their family carers' attribution of social changes in dementia and the consequences of these attributions.

DESIGN

Qualitative study, using a semi-structured interview guide. Individual interviews continued to theoretical saturation. Two researchers independently analysed interview transcripts.

SETTING AND PARTICIPANTS

People with mild dementia and family carers purposively selected from London-based memory services for diverse demographic characteristics to encompass a range of experiences.

PRIMARY AND SECONDARY OUTCOMES

Attribution of social changes experienced by the person with dementia and the consequences of these attributions.

RESULTS

We interviewed nine people with dementia and nine carers, encompassing a range of age, ethnicity and educational backgrounds.Both groups reported that the person with dementia had changed socially. People with dementia tended to give one or two explanations for social change, but carers usually suggested several. People with dementia were often socially embarrassed or less interested in going out, and they or their relatives' physical illness or fear of falls led to reduced social activity. Carers often attributed not going out to a choice or premorbid personality. Carers found that their relative needed more support to go out than they could give and carers needed time to themselves because of carer stress or other problems from which they shielded the person with dementia. Additionally, there was decreased opportunity to socialise, as people were bereaved of friends and family. Participants acknowledged the direct impact of dementia symptoms on their ability to socially engage but sometimes decided to give up socialising when they knew they had dementia. There were negative consequences from social changes being attributed to factors such as choice, rather than dementia.

CONCLUSION

Clinicians should ask about social changes in people with dementia. Explaining that these may be due to dementia and considering strategies to overcome them may be beneficial.

A Critical Ethnography of the Process of Discharge Decision-Making for Elderly Patients

A critical ethnography of the process of discharge decision-making for elderly patients was conducted to examine the nature of the process over the total course of patients' hospital stays. The focus was on describing the timing and conditions of decision-making, the related activities of professionals, professionals' perceptions of the process, and the effects of the process on those involved and on the hospital organization. Data analysis demonstrated that the process is not intricately linked with patients' clinical progress, that often inaccurate assumptions about the importance of patient-related clinical and social factors and organizational parameters underlie decisions, and that professionals' perceptions of the process are shaped by organizational imperatives. In the current process, resources are used inefficiently and humanitarian and ethical consequences arise for participants. The analysis supports attempts to achieve greater congruence between the discharge decision process and the patient's clinical progress so that the fiscal and humanitarian goals of the hospital can be achieved.

Making sense of behavioral disturbances in persons with dementia: Latino family caregiver attributions of neuropsychiatric inventory domains

The purpose of this study was to describe the nature and frequency of Latino family caregiver attributions for dementia-related neuropsychiatric symptoms. This is a cross-sectional study conducted in the Sacramento, California area. Participants were 30 Latino family caregivers of community-dwelling Latino elderly meeting research criteria for dementia who were selected from an ongoing cohort study of older Latinos (Sacramento Area Latino Study on Aging). Open-ended probes were used to elicit caregiver attributions for each symptom domain of the Neuropsychiatric Inventory. Across the 30 caregivers, 121 explanations for neuropsychiatric domains were present. Content analysis of these explanations revealed 7 different attribution categories (ie, Alzheimer disease, interpersonal problems, other medical conditions, personality, mental, aging, and genetics). Overall, Alzheimer disease was the most frequent attribution category but accounted for less than 30% of the total attributions. In conclusion, this study found that Latino caregivers were more likely to attribute neuropsychiatric symptoms to causes other than Alzheimer disease or a related dementia.

What is appropriate health care for end-stage dementia?

OBJECTIVE

This study sought to determine the kind of health care that professional and family caregivers viewed as appropriate for end-stage dementia patients.

DESIGN

Survey.

PARTICIPANTS

All 819 physician members and 1,000 randomly selected non-physician members of the Gerontological Society of America and 500 families of demented relatives from the Alzheimer's Association.

MEASURES

Respondents chose the appropriate level of care from five choices on a continuum from highly aggressive to palliative.

RESULTS

The majority of physicians who cared for elders (61%), gerontologists from other professions (55%), and families (71%) chose palliative care only. Increased age of the respondent and experience with terminal care choices were associated with the choice of palliative care. The majority favored hospice care for patients with end-stage dementia.

CONCLUSIONS

Professional and family members of demented individuals, especially if they have experience in terminal care decisions, strongly favor palliative care for end-stage dementia. These findings may be helpful to professionals and families dealing with these choices.

Health care professionals and family involvement in care-related decisions concerning older patients

This article examines care-related decision making within the context of in-home family care. It also uses the Andersen-Newman model to identify the correlates of physician involvement and centrality in decision making and the impact that it has on family members' caregiving satisfaction. Analysis of data from 244 family caregivers shows that elders (40%) and nuclear kin (53%) are key decision makers, indicating that families prefer to control care-related decisions. However, physicians are part of the decision-making process for nearly one fourth of the families in this study. The patient's impairment and the caregiver's education correlate with physician involvement in decision making. Shared residence and caregiver's overall satisfaction with the caregiving process correlate with physician centrality on the network. Discussion centers on implications for physician interactions with caregiving families around decision making. Included are indications for improved communication in decision-making contexts.

The ageing family in crisis: assessment and decision-making models

The purpose of this paper is to present a multidisciplinary model for use with elderly families in crisis and decision making. The application of systems in family assessment theory is outlined in order to understand the complexities of family assessment and decision making. A schematic family assessment and decision-making model is discussed. These models identify what the problem is, the family structure and supports, and possible interventions and evaluation. Ineffective processing strategies such as regression and premature closure are reviewed, and strategies for effective decision making are outlined.