Dr. Kathryn L. Moseley is a clinical bioethicist as well as board-certified pediatrician and neonatologist. For eleven years, Dr.
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The CBS News website recently featured 10 tips to make better decisions about cancer care from U-M’s Angela Fagerlin, Ph.D., associate professor of internal medicine. Below is an excerpt from the article:
Cancer is scary, and doctors sometimes sound as if they’re speaking a foreign language when talking about the disease and its treatment. But “people are making life and death decisions that may affect their survival and they need to know what they’re getting themselves into,” says Fagerlin “Cancer treatments and tests can be serious. Patients need to know what kind of side effects they might experience as a result of the treatment they undergo.”
Geoffrey Barnes was featured in a recent MHealth Lab article, "Medication Adherence a Problem in Atrial Fibrillation Patients." Dr. Barnes is the lead author of JAMA Cardiology article, which reports that while anticoagulant therapy is important for stroke prevention in people with atrial fibrillation, many people don’t stick with it for various reasons (side effects, physician advice, etc.).
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.
Reshma Jagsi was recently quoted in the Reuters Health News article, "How consent requirements may shape teen mental health research."
Sarah Hawley is featured in ClickOnDetroit news item,"The debate over breast cancer treatment" in which Local 4's Rhonda Walker takes a closer look at the aggressive treatment more and more woman who are facing breast cancer are choosing.
Tanner Caverly was recently interviewed for U.S. News & World Report on the risks and benefits of lung cancer screening. According to Dr. Caverly, it important to tailor the conversation about screening because the benefit-versus-risk calculation differs for each patient.
Brian Zikmund-Fisher, PhD, was featured in an interview by the U-M News Service on September 29, 2010. Dr. Zikmund-Fisher served as the featured guest editor for a special supplement to Medical Decision Making, Sept/Oct 2010, that focused on the DECISIONS study. In the interview, Dr. Zikmund-Fisher highlighted the need for health care providers to do a better job of educating patients about the medical decisions they face. A video highlights the findings of the study and can be found at: http://ns.umich.edu/htdocs/releases/story.php?id=8008. CBSSM faculty also involved in the DECISIONS study included Angela Fagerlin, PhD, and Mick Couper, PhD.
Reshma Jagsi’s survey of high-achieving physician-scientists published in JAMA, found that nearly a third of women reported experiencing sexual harassment. As women now make up about half of medical school students, the researchers emphasize the importance of recognizing unconscious bias as well as overtly inappropriate behaviors.
1. Reshma Jagsi, Kent A. Griffith, Rochelle Jones, Chithra R. Perumalswami, Peter Ubel, Abigail Stewart. Sexual Harassment and Discrimination Experiences of Academic Medical Faculty. JAMA, 2016; 315 (19): 2120 DOI: 10.1001/jama.2016.2188
Peter Ubel, MD, is a physician and behavioral scientist whose research and writing explores the quirks in human nature that influence people's lives — the mixture of rational and irrational forces that affect health, happiness and the way society functions.
Dr. Ubel is Professor of Marketing and Public Policy at Duke University. He was Professor of Medicine and Psychology at the University of Michigan, where he taught from 2000 to 2010, and from 2005-2010, served as the Director of the Center for Behavioral and Decision Sciences in Medicine.