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Sarah Hawley's perspective piece, "Half of women with early-stage breast cancer consider prophylactic double mastectomy" was recently published in Healio ITJ (in the journals).

Full article can be found here.

Ken Langa, MD, PhD

Faculty

Dr. Langa is the Cyrus Sturgis Professor in the Department of Internal Medicine and Institute for Social Research, a Research Scientist in the Veterans Affairs Center for Clinical Management Research, and an Associate Director of the Institute of Gerontology, all at the University of Michigan. He is also Associate Director of the Health and Retirement Study (HRS), a National Institute on Aging funded longitudinal study of 20,000 adults in the United States ( http://hrsonline.isr.umich.edu ).

Last Name: 
Langa

Thomas Valley, MD

Faculty

Tom Valley is an Assistant Professor in the Division of Pulmonary and Critical Care Medicine in the Department of Internal Medicine at the University of Michigan. He received his undergraduate degrees in history and chemistry from Emory University, and his medical degree from the University of Miami. He completed his internal medicine residency and chief residency at the University of Texas-Southwestern/Parkland Memorial Hospital.

Last Name: 
Valley

Funded by National Institutes of Health; Nationatal Institute on Aging

Funding Years: 2012-2017

A cornerstone of the nation’s social science research infrastructure, the Panel Study of Income Dynamics (PSID) is a longitudinal survey of a nationally representative sample of U.S. families. Begun in 1968, 36 waves of data have now been collected on PSID families and their descendents. Its long-term measures of economic and social well-being have spurred researchers and policy makers to attend to the fundamental dynamism inherent in social and behavioral processes. This project collects, processes, and disseminates three modules in the 2013 and 2015 waves of the PSID:
1.Health module: Including 15 minutes of survey questions on health status, health behaviors, health insurance coverage & health care costs. Linkages to the National Death Index and Medicare will be extended;
2.Wealth module: Including 10 minutes of survey questions on wealth, active savings, and pensions. Linkage to Social Security earnings and benefits records for active sample and decedents will be undertaken for the first time, and a new module to minimize errors in reports of wealth changes will be developed and implemented; and
3.Well-being module with related psychosocial measures: A mixed-mode (web/mail out) questionnaire to collect content from both respondents and spouses about their well-being and related psychosocial measures (e.g., personality, intelligence), with an experiment to identify (and allow researchers to adjust for if necessary) mode effects.

PI(s): Robert Schoeni

Co-I(s): Mick Couper, Vicki Freedman, Katherine McGonagle

Supporting information for: 2017 CBSSM Research Colloquium and Bishop Lecture (Norman Daniels, PhD)


"Setting priorities for Medicaid: The views of minority and underserved communities"
Presenter: Susan Goold, MD, MHSA, MA


Co-authors: Lisa Szymecko, JD, PhD; H. Myra Kim, ScD; Cengiz Salman, MA; A. Mark Fendrick, MD; Edith Kieffer, MPH, PhD; Marion Danis, MD, Zachary Rowe, BBA


Setting priorities for state Medicaid programs challenges policy makers. Engaging beneficiaries affected by tradeoffs could make allocations more just and more sensitive to their needs. 

Academic-community partnerships adapted the simulation exercise CHAT (CHoosing All Together) to engage community members in deliberations about Medicaid spending priorities.  After an informational video about Medicaid, individuals and deliberating groups choose from a menu of spending options constrained by limited resources. We randomly assigned participants from low-income communities throughout Michigan to participate in CHAT with (n=209) or without group deliberations (n=181) in English, Spanish or Arabic. Data collection included pre- and post-CHAT individual priorities and group priorities.

Low-income participants ranged from 18 to 81 years old (Mean 48.3); 61.6% were women. Over half (56.7%) self-identified as white, 30.8% African-American, 17.3% Hispanic, 9.2% Native American, and 12.1% Arab, Arab-American or Chaldean. Most (65.9%) had a chronic condition and 30.3% reported poor or fair health.

Before CHAT, most participants prioritized eligibility consistent with Medicaid expansion. They also prioritized coverage for a broad range of services. Most accepted daily copays for elective hospitalization (71.6% deliberators, 67.9% controls) and restricted access to specialists (60.2% deliberators, 57.4% controls). Deliberators were more likely than controls to increase, after deliberations, what they allocated to mental health care (between arm difference in allocation=0.22, p=.03) and eligibility (between arm difference in allocation=0.18, p=.04). Deliberating groups also prioritized eligibility; only 3 of 22 chose pre-expansion eligibility criteria, and 9 of 22 chose to expand eligibility further.

Members of underserved communities in Michigan put a high priority on Medicaid expansion and broad coverage. When given the opportunity to deliberate about priorities,  participants increased the priority given to expanded eligibility and coverage for mental health services.


"How Acceptable Is Paternalism? A Survey-Based Study of Clinician and Non-clinician Opinions on Decision Making After Life Threatening Stroke"
Presenter: Kunal Bailoor, MD Candidate


Co-authors: Chithra Perumalswami, MD, MSc; Andrew Shuman, MD; Raymond De Vries, PhD; Darin Zahuranec, MD, MS


Complex medical scenarios may benefit from a more paternalistic model of decision making. Yet, clinicians are taught to value patient autonomy, especially at the end-of-life. Little empirical data exist exploring opinions on paternalism.

Methods: A vignette-based survey exploring surrogate decision making after hemorrhagic stroke was administered to clinicians (faculty, residents, and nurses) at an academic health center, and non-clinicians recruited through a university research volunteer website. The cases involved an urgent decision about brain surgery, and a non-urgent decision about continuation of life support one week after stroke. Respondents rated the acceptability of paternalistic decision making, including clinicians not offering or making an explicit recommendation against the treatment, on a 4 point Likert scale.

Results: Of 924 eligible individuals, 818 (649 non-clinicians, 169 clinicians) completed the survey (completion rate 89%).  A minority of respondents (15.3%) found it acceptable not to offer surgery. Most believed it was acceptable to make an explicit recommendation that would likely result in death (73% for avoiding surgery, 69% for stopping the ventilator). Clinicians were more likely than non-clinicians to consider not offering surgery acceptable (30% vs 11%, p<0.0001). Clinicians were more likely to consider recommendations against surgery acceptable (82% vs 71%, p=0.003) and to consider recommendations to discontinue the ventilator acceptable (77% vs 67%, p=0.02). There were no differences between the nurse and physician acceptability ratings (p=0.92).

Conclusions: Clinicians and the lay public differ on the acceptability of paternalistic decision making. Understanding these differences are vital to improving communication between clinicians, patients, and families.


"Ethical Challenges Faced by Providers in Pediatric Death: A Qualitative Thematic Analysis"
Presenter: Stephanie Kukora, MD


Co-authors: Janice Firn, PhD, MSW; Patricia Keefer, MD; Naomi Laventhal, MD, MA
 

Background: Care providers of critically ill patients encounter ethically complex and morally distressing situations in practice. Though ethics committees guide ethical decision-making when conflicts arise in challenging cases, they rarely address routine needs of individual providers. Without ethics education, providers may lack skills necessary to resolve these conflicts or insight to recognize these dilemmas.

Objective: We sought to identify whether providers remark on ethical dilemmas/moral distress without being specifically prompted, when asked to comment on a recent in-hospital pediatric death. We also sought to characterize the nature of dilemmas or distress if found.

Methods: Providers involved in a deceased child’s care in the 24 hours prior to death were electronically surveyed. Questions included demographic information and free-text response. Free-text responses were thematically analyzed in Dedoose.

Results: There were 307 (35%) free-text responses in 879 completed surveys (33% total response rate), regarding the deaths of 138 patients (81% of in-hospital pediatric deaths) from November 2014 to May 2016. Multidisciplinary care team members from diverse hospital units were represented. 52 respondents described ethical challenges and/or moral distress. Disagreement/regret was a major theme, with subthemes of futility, suffering, and “wrong” medical choice made. Failure of shared decision-making was also a major theme, with subthemes of autonomy and best interest, false hope, denial, and misunderstanding/disagreement between the family and medical team. Some providers revealed personal ethical struggles pertaining to their role, including medication provision for pain at the end of life, struggling to be “truthful” while not divulging information inappropriate for their role, and determining when providing comfort care is ethically permissible.

Discussion/Conclusion: Providers experience ethical conflicts with pediatric end-of-life care but may be unwilling or unable to share them candidly. Education assisting staff in identifying and resolving these dilemmas may be helpful. Further support for providers to debrief safely, without criticism or repercussions, may be warranted.


"Capacity for Preferences:  An overlooked criterion for resolving ethical dilemmas with incapacitated patients"
Presenters: Jason Adam Wasserman, PhD; Mark Navin, PhD
 

Clinical bioethics traditionally recognizes a hierarchy of procedural standards for determining a patient’s best plan of care. In broad terms, priority is given first to autonomous patients themselves and then to surrogates who utilize substituted judgments to choose as they believe the patient would have chosen. In the absence of good information about what the patient would have wanted, clinical ethicists typically retreat to the “best interest” standard, which represents a relatively objective assessment designed to maximize benefits and/or minimize harms.  In this paper, we argue that “capacity for preferences” is a conceptually distinct and morally salient procedural standard for determining a patient’s best plan of care.  We build our argument on the grounds that 1) that many patients who lack decisional capacity can nevertheless reliably express preferences (an empirical claim); 2) these preferences are distinct from best interest and not reducible to best interest considerations; 3) that capacity for preferences, at a minimum, has moral valence for situations in which best interest is undetermined (and we argue this happens more frequently than commonly recognized); and, finally, 4) that capacity for preferences in incapacitated patients lacking reliable or valid surrogates might even subvert a best interest course of action in some cases.  Some precedent for our analysis can be found in the concept of pediatric assent. However, the idea that patient preferences matter morally has broad application for adult patients, including for those with advanced dementia and other mental illnesses that preclude capacity for decision-making.

Fri, October 07, 2011

The University of Michigan Health System sent out a press release today describing the Institute of Medicine report on the future of the nation's health care.  In the report, two U-M health care initiatives were recommended to the U.S. Secretary of Health and Human Services; one of those initiatives was Susan Goold's Choosing Healthcare All Together (CHAT) simulation exercise that engages the public in setting health care priorities. 

Adam Marks, MD

Faculty

Dr. Marks is associate director of the adult Palliative and Supportive Care Clinic at the East Ann Arbor Health and Geriatrics Center, as well as the Adult Palliative Care medical director at Arbor Hospice. He received his medical degree and masters of public health from the Wisconsin School of Medicine and Public Health in Madison, Wisconsin. He completed his combined internal medicine-pediatrics residency at the University of Michigan, where he also completed his fellowship training in palliative care.

Last Name: 
Marks

Julie Wright Nunes, MD, MPH

Faculty

Julie Wright Nunes is an Assistant Professor at the University of Michigan Department of Internal Medicine. Her research interests include Chronic Kidney Disease (CKD) and its prevention and also the development of methods and tools to help facilitate and optimize provider-directed CKD patient education.

Last Name: 
Wright Nunes

Peter A. Ubel has been selected by the Robert Wood Johnson Foundation as a recipient of a prestigious Investigator Award in Health Policy Research for 2008. Dr. Ubel, who was director of the Center for Bioethics and Social Sciences in Medicine, plans to examine how beliefs about quality of life affect the choices made when patients seek treatment, when payers determine coverage policies, and when policy-makers weigh programmatic or financial options. His project, Emotional Adaptation and the Goals of Health Care Policy, will introduce insights from well-being research, which studies how physical illness and emotional well-being are intertwined, to debates about cost-effectiveness of medical treatments, coverage decisions by payers, and discussions about health care priorities.

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