Search Results (30)

Background/Objectives: To avoid becoming mired in prolonged deep dementia, some people seek to hasten death by advance instructions rejecting life-sustaining medical intervention (LSMI) at a point of cognitive decline they define in advance as unacceptable. When the time comes to implement such advance instructions and to allow the person in advanced dementia to die, many clinicians experience moral and ethical qualms. The decision makers face a clash between people’s legally recognized self-determination prerogative to control their post-competence medical fate and the decision makers’ conviction that humane treatment dictates sustaining the well-being, i.e., the physical “best interests,” of the patient who no longer recalls prior instructions grounded in concerns about personal dignity. The authors’ objective here is to provide guidance in resolving this anguishing dilemma confronting medical decision makers. Methods: The authors construct and analyze a case scenario involving a patient in a state of advanced dementia with a clear advance instruction rejecting LSMI at the current point of debilitation, but who is not ostensibly suffering, is experiencing a modicum of life satisfaction, and is making life-affirming utterances. The two lead authors present contrasting views on whether legal and moral factors impel the implementation of the advance directive rejecting treatment or rather dictate life-sustaining medical intervention. Results: At this early stage of jurisprudence involving persons in advanced dementia, there can be no definitive resolution of the difficult legal/moral clash confronting decision makers. Some sources would conclude that persons are legally entitled to define precipitous mental decline and complete dependence on others as intolerably undignified and inconsistent with their self-defined life narrative. Other sources would be guided by humane respect for the contemporary well-being of a non-suffering patient, especially one making life-affirming utterances. Conclusion: Through the lens of this illuminating case and contrasting analyses, readers should better understand how clinicians should weigh advance directives against shifting care preferences subsequently articulated by persons with advanced dementia. Full article

In the current clinical psychiatric practice in most of the world, treatment decisions are based on a person’s capacity to make these decisions. When a person lacks the capacity to understand and appreciate treatment decisions, in many jurisdictions a third-party substitute decision maker (SDM) is appointed on his or her behalf in order to promote safety and optimal clinical outcome. In Ontario, Canada, for example, family members (typically) or public guardians are appointed as SDMs, and they form an integral part of the medical–legal system in psychiatric care. Clinicians working with both patients and their SDMs in these circumstances encounter unique challenges and deliver care in specialized ways, though little research has focused on their experiences and reflections. Based on focus group data, this qualitative study uses a descriptive and interpretative phenomenological approach through thematic analysis to examine these aspects from clinicians working in both inpatient and outpatient settings of an urban teaching hospital’s psychiatric services in Toronto, Canada. Seven key themes emerged: Clinicians (1) appreciate hardships and challenges in lives of SDMs and patients—including the challenging emotions and experiences on both sides, and the risks and relational changes from being an SDM; (2) have an understanding of the patient’s situation and respect for patient autonomy and wishes—they are promoter of autonomy and mindful of patients’ prior wishes amidst patients’ fluctuating capacity, facilitating communication, keeping patients informed and promoting transitioning from SDM to self-determination; (3) have a special working relationship with family SDMs—including supporting SDMs, avoiding harm from delayed or denied treatment, and educating and collaborating with SDMs while maintaining professional boundaries; (4) at times find it difficult working with SDMs—stemming from working with over-involved or uninterested family SDMs, coping with perceived poor SDM decisions, and they sometimes ponder if SDMs are necessary; (5) delineate differences between family and Public Guardian and Trustee (PGT) SDMs—they see PGT as closely aligned with medical decision makers, while family SDMs are more intimately involved and more likely to disagree with a physician’s recommendation; (6) recognize the importance of the SDM role in various contexts—through seeing social values in having SDMs, and acknowledging that having SDMS help them to feel better about their actions as they work to protect the patients; and (7) express ideas on how to improve the current system—at public, societal, and family SDM levels. We conclude that clinicians have unique mediating roles, with privilege and responsibility in understanding the different roles and challenges patients and SDMs face, and have opportunities to improve patient and SDM experiences, clinical outcomes, carry out education, and advocate for ethically just decisions. These clinical roles also come with frustration, discomfort, moral distress and at times vicarious trauma. Clinicians’ unique understanding of this complex and nuanced intersection of patient care provides insight into the core issues of autonomy, duty to care and protect, advocacy, and emotional dynamics involved in this sector as a larger philosophical and social movement to abolish SDMs, as advocated by the Convention on the Rights of Persons with Disability (CRPD), is taking place. We briefly discuss the role of supported decision making as an alternative as. Full article

Background/Objectives: Artificial intelligence (AI) has emerged as a promising field in the era of personalized oncology due to its potential to save time and workforce while serving as a supportive tool in patient management decisions. Although several studies in the literature have explored the integration of AI into oncology practice across different tumor types, available data remain limited. In our study, we aimed to evaluate the role of AI in the management of complex cancer cases by comparing the decisions of an in-house tumor board and ChatGPT-4o for patients with various tumor types. Methods: A total of 102 patients with diverse cancer types were included. Treatment and follow-up decisions proposed by both the tumor board and ChatGPT-4o were independently evaluated by two medical oncologists using a 5-point Likert scale. Results: Analysis of agreement levels showed high inter-rater reliability (κ = 0.722, p < 0.001 for tumor board decisions; κ = 0.794, p < 0.001 for ChatGPT decisions). However, concordance between the tumor board and ChatGPT was low, as reflected in the assessments of both raters (Rater 1: κ = 0.211, p = 0.003; Rater 2: κ = 0.376, p < 0.001). Both raters more frequently agreed with the tumor board decisions, and a statistically significant difference between tumor board and AI decisions was observed for both (Rater 1: Z = +4.548, p < 0.001; Rater 2: Z = +3.990, p < 0.001). Conclusions: These findings suggest that AI, in its current form, is not yet capable of functioning as a standalone decision-maker in the management of challenging oncology cases. Clinical experience and expert judgment remain the most critical factors in guiding patient care. Full article

Advance care planning (ACP) involves longitudinal communication between the patient and physician to explore the patient’s wishes and goals while relaying accurate diagnostic and prognostic information to support informed and shared medical decision-making. In pediatrics, it also uniquely involves the parents or legal guardians as the primary medical decision-makers. ACP ideally leads to the implementation of advanced directives (ADs) and can be a difficult concept to discuss with pediatric patients and families with refractory oncologic disease, given the distinctive burdens that accompany this population. Many obstacles can delay the initiation of these conversations with these families, although existing literature supports beginning ACP conversations at the time of initial diagnosis and treatment. Parents or legal guardians often serve as the sole decision maker for pediatric patients but there has also been a shift in the literature to include children/adolescents in conversations regarding ADs and other aspects of end-of-life (EOL) care, an essential aspect of patient-centered ACP. This guidance is unfortunately not often translated into clinical practice. In this review, we aim to define and discuss the current status, obstacles, and benefits surrounding early initiation of ACP conversations with children or adolescents with advanced cancer and their families. We also discuss how physicians and the medical team, including pediatric palliative care, can increase the degree of pediatric patient involvement in ACP and EOL discussions, as developmentally appropriate, and mitigate delays in discussing ACP with these families and patients. Full article

The global Internet of Medical Things (IoMT) market is growing at a Compound Annual Growth Rate (CAGR) of 17.8%, a testament to the increasing demand for IoMT in the health sector. However, more IoMT devices mean an increase in the volume and velocity of data received by healthcare decision-makers, leading many to develop Distributed Decision Support Systems (DDSSs) to help them make accurate and timely decisions. This research is a systematic review of DDSSs in healthcare using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. The study explores how advanced technologies such as Artificial Intelligence (AI), IoMT, and blockchain enhance clinical decision-making processes. It highlights key innovations in DDSSs, including hybrid imaging techniques for comprehensive disease characterization. It also examines the role of Case-Based Reasoning (CBR) frameworks in improving personalized treatment strategies for chronic diseases like diabetes mellitus. It also presents challenges of applying DDSSs in the healthcare sector, such as security and privacy, system integration, and interoperability issues. Finally, it discusses open issues as future research directions in the field of DDSSs in the healthcare sector, including data structure standardization, alert fatigue for healthcare workers using DDSSs, and the lack of adherence of emerging technologies like blockchain to medical regulations. Full article

Introduction: Stroke is a major cause of mortality and disability worldwide. It is one of the foremost non-communicable diseases and the third leading cause of death in Bangladesh. Bangladesh is a developing country and as such, the prevalence, risk factors and management of the condition has some differences with more Westernised populations. In this review, we look at the epidemiology of stroke in Bangladesh and what barriers exist to improving stroke care in this country. Methods: A systematic search of the PubMed database, Mymensingh Medical Journal, Bangladesh Journal of Neuroscience and Google Scholar was conducted for articles relating to stroke in Bangladesh. Results: The incidence of stroke in Bangladesh is 3 strokes per 1000 people. The prevalence of haemorrhagic stroke is higher than in Western populations, and novel risk factors such as sitting in a squatting position and betel nut chewing increase a Bangladeshi’s stroke risk. A lack of education on stroke symptoms and a poor internal infrastructure are the main barriers to improving stroke care in this country. Conclusions: Stroke in Bangladesh is associated with traditional risk factors and non-traditional risk factors that are behaviourally ingrained into the local culture. Improved outcomes for these patients will rely on education programmes for the population, a regard for these risk factors and improving the availability of evidence-based treatments. Innovative approaches from policy decision makers to enhance equitable access to stroke services may help in providing stroke care in Bangladesh. Full article

An analysis of patient satisfaction in the context of healthcare reflects the patient’s perception of actual care through the prism of their expectations of ideal care. A study was conducted to investigate patient satisfaction with postoperative care in the context of improvements in hospital medical services (renovations and modernization of operating rooms and wards with beds, endowments in medical equipment for investigation and treatment, new work procedures, and revisions of existing procedures). Statistical analysis was performed based on the questionnaires distributed to patients hospitalized in the surgical wards of the Bihor County Emergency Clinical Hospital, between 2019 and 2023. A total of 4018 questionnaires were collected, and after the elimination of questionnaires with incomplete or incorrect data, 3985 remained in the analysis. Of the total of 2994 people who reported having undergone surgery, a total of 2090 responded to the questions that focused on postoperative care and overall impression of the hospital. No statistically significant differences in patient satisfaction by sociodemographic factors were found. A statistically significant increase in patient satisfaction with postoperative care and overall impression of the hospital was observed over the last 5 years. Correlation testing between postoperative care responses and overall impression, using the Sperman method, shows a directly proportional relationship between the two variables. In the future, it is necessary to extend the patient satisfaction questionnaire to comprehensively analyze the surgical component in order to identify gaps in postoperative care, helping decision makers to improve the medical services provided to patients. Full article

The possible threats that healthcare waste management (HWM) poses to the environment and public health are making it more and more crucial for medical facility administrators to be worried about it. This is in line with the global trend towards firms giving sustainability more of a priority. Many organizations, including the World Health Organization (WHO) and other organizations, as well as national and state laws, have mandated the proper disposal of infectious and hazardous healthcare waste. To effectively address the complex problem of selecting the best treatment option for HWM, a multi-criteria decision-making (MCDM) procedure must be used. The alternative ranking order method accounting for two-step normalization (AROMAN) methodology is provided in the context of q-rung orthopair fuzzy environment. This method comprises two steps of normalization and is based on the criteria importance through intercriteria correlation (CRITIC) paradigm. Whereas the AROMAN methodology uses vector and linear normalization techniques to improve the accuracy of the data for further computations, the CRITIC method assesses the intercriteria correlations and scores the significance of each criterion. The ranking from the proposed method is $A{l}_5>A{l}_4>A{l}_3>A{l}_1>A{l}_2$. The study’s conclusions indicate that recycling ($A{l}_5$) is the best option since it lessens trash production, aids in resource recovery, and protects the environment. Using this method helps decision makers deal with subjectivity and ambiguity more skillfully, promotes consistency and transparency in decision making, and streamlines the process of choosing the best waste management system. Sustainable waste management practices have been implemented in the biomedical industry with some success. The proposed technique is a helpful tool for legislators and practitioners seeking to improve waste management systems. Full article

The healthcare industry is one application for data envelopment analysis (DEA) that can have significant benefits for standardizing health service delivery. This narrative review focuses on the application of DEA in emergency departments (EDs) and the management of emergency conditions such as acute ischemic stroke and acute myocardial infarction (AMI). This includes benchmarking the proportion of patients that receive treatment for these emergency conditions. The most frequent primary areas of study motivating work in DEA, EDs and management of emergency conditions including acute management of stroke are sorted into five distinct clusters in this study: (1) using basic DEA models for efficiency analysis in EDs, i.e., applying variable return to scale (VRS), or constant return to scale (CRS) to ED operations; (2) combining advanced and basic DEA approaches in EDs, i.e., applying super-efficiency with basic DEA or advanced DEA approaches such as additive model (ADD) and slack-based measurement (SBM) to clarify the dynamic aspects of ED efficiency throughout the duration of a first-aid program for AMI or heart attack; (3) applying DEA time series models in EDs like the early use of thrombolysis and percutaneous coronary intervention (PCI) in AMI treatment, and endovascular thrombectomy (EVT) in acute ischemic stroke treatment, i.e., using window analysis and Malmquist productivity index (MPI) to benchmark the performance of EDs over time; (4) integrating other approaches with DEA in EDs, i.e., combining simulations, machine learning (ML), multi-criteria decision analysis (MCDM) by DEA to reduce patient waiting times, and futile transfers; and (5) applying various DEA models for the management of acute ischemic stroke, i.e., using DEA to increase the number of eligible acute ischemic stroke patients receiving EVT and other medical ischemic stroke treatment in the form of thrombolysis (alteplase and now Tenecteplase). We thoroughly assess the methodological basis of the papers, offering detailed explanations regarding the applied models, selected inputs and outputs, and all relevant methodologies. In conclusion, we explore several ways to enhance DEA’s status, transforming it from a mere technical application into a strong methodology that can be utilized by healthcare managers and decision-makers. Full article

Background and Objectives: During the COVID-19 pandemic, Serbia has faced devastating losses related to increased mortality rates among men and women of all ages. With 14 registered cases of maternal death in 2021, it became obvious that pregnant women are faced with a serious threat that jeopardises their life as well as the life of their unborn child. Studying the consequences of the COVID-19 pandemic on maternal outcomes is vivifying and stimulating for many professionals and decision-makers, and knowing the contextual characteristics can facilitate the application of literature findings in practice. Therefore, the aim of this study was to present findings of maternal mortality in Serbia associated with SARS-CoV-2 infected and critically ill pregnant women. Methods: Clinical status and pregnancy-related features were analysed for a series of 192 critically ill pregnant women with confirmed SARS-CoV-2 infection. According to the treatment outcome, pregnant women were divided in two study groups: a group of survivors and a group of deceased patients. Results: A lethal outcome was recorded in seven cases. Pregnant women in the deceased group were presenting at admission more commonly with X-ray–confirmed pneumonia, a body temperature of >38 °C, cough, dyspnea, and fatigue. They were more likely to have a progression of the disease, to be admitted to intensive care unit, and be dependent from mechanical ventilation, as well as to have nosocomial infection, pulmonary embolism, and postpartum haemorrhage. On average, they were in their early third trimester of pregnancy, presenting more commonly with gestational hypertension and preeclampsia. Conclusions: Initial clinical manifestations of SARS-CoV-2 infection, such as dyspnea, cough, fatigue, and fever, could be a potent factors in risk stratification and outcome prediction. Prolonged hospitalization, ICU admission, and associated risk of hospital-acquired infections require strict microbiological surveillance and should be a constant reminder of rational antibiotics use. Understanding and identification of risk factors associated with poor maternal outcomes among pregnant women infected with SARS-CoV-2 should warn medical professionals of potentially unwanted outcomes and can be used for organising an individualised treatment for a pregnant patient’s specific needs, including a guide to necessary consultations with medical specialists in various fields. Full article

In this paper, we review the ethical issues involved in providing information to, and obtaining consent (for treatment and/or research) from patients in the intensive care unit. We first review the ethical obligations of the physician in treating patients, who are by definition, vulnerable, and often unable to assert their autonomy during situations of critical illness. Providing clear and transparent information to the patient about treatment options or research opportunities is an ethical and, in some cases, legal obligation for the physicians, but may be rendered difficult, not to say impossible in the intensive care unit by the patient’s health state. In this context, we review the specificities of intensive care with respect to information and consent. We discuss who the right contact person is in the ICU setting, with possible choices including a surrogate decision maker, or a member of the family, in the absence of an officially designated surrogate. We further review the specific considerations relating to the family of critically ill patients, and the amount and type of information that may be given to them without breaching the tenets of medical confidentiality. Finally, we discuss the specific cases of consent to research, and patients who refuse care. Full article

Nowadays, according to the intention of many hospitals and medical centers to computerize their processes and medical treatments, including data forms and medical images, which are generating a considerable amount of data, IT specialists and data scientists who are oriented to eHealth and related issues know the importance of data integration and its benefits. This study indicates the significance of data integration, especially in medical information systems. It means that the medical subsystems in the HIS (hospital information system) must be integrated, and it is also necessary to unify with the MIS (management information system). In this paper, the accuracy level of the extracted reports from the information system (to evaluate the staff’s performance) will be measured in two ways: (1) At first, the performance of the clinic reception staff will be evaluated. In this way, the personnel attendance system is an independent and separate software, and the mentioned evaluation has been performed by its report. (2) The following year, in the same location, the same evaluation has been performed based on the data extracted from the personnel attendance subsystem, which has been added to the medical information system as an integrated information system. After comparing the accuracy level of both ways, this paper concludes that when the personnel attendance subsystem as a part of the MIS has been unified with the HIS, the reports and, consequently, management decisions will be more accurate; therefore, the managers and decision-makers will perceive the importance of data integration more than in the past. Full article

Regional eco-efficiency affects local public health through intermediaries such as economic and environmental impacts. Considering multiple factors, the implicit and uncertain relationship with regional characteristics, and the limited data availability, this paper investigated the forecasting of changes in local public health—including the number of visits to hospitals (VTH), outpatients with emergency treatment (OWET), number of inpatients (NI), number of health examinations (NOHE), and patients discharged (PD)—using calculated regional eco-efficiency with the Least Square-Support Vector Machine-Forecasting Model and acquired empirical evidence, utilizing the province-level data in China. Results: (1) regional eco-efficiency is a good predictor in both a single and multi-factor situation; (2) the prediction accuracy for five dimensions of the changes in local public health was relatively high, and the volatility was lower and more stable throughout the whole forecasting period; and (3) regional heterogeneity, denoted by three economic and demographic factors and three medical supply and technical level factors, improved the forecasting performance. The findings are meaningful for provincial-level decision-makers in China in order for them to know the current status or trends of medical needs, optimize the allocation of medical resources in advance, and enable ample time to tackle urgent emergencies, and, finally, the findings can serve to evaluate the social effects of improving regional eco-efficiency via local enterprises or individuals and adopting sustainable development strategies. Full article

The registered nurse has crucial preventative, therapeutic, sociocultural, and advocacy roles in promoting quality holistic patient-centred palliative care. This paper examines, describes, and analyses this multifaceted role from an antipodean perspective. We conducted systematic searches using PubMed, Google Scholar, government guidelines, authoritative body regulations, quality control guidelines, and government portals pertaining to palliative care nursing in Australia. This paper relies upon the information garnered from publications, reports, and guidelines resulting from these searches and analyses. The fundamental principles and guiding values of palliative care (and nursing) and the raison d’etre for palliative care as a discipline are underscored and expanded on. Australian Clinical Practice Guidelines (CPGs) pertaining to palliative end-of-life (EOL) nursing care and associated services are discussed. The relevant NMBA nursing standards that RNs need to have to administer opioids/narcotics in palliative care are summarised. The identification of patients who need EOL care, holistic person-centred care planning for them, and consultative multidisciplinary palliative clinical decision making are discussed in the palliative care context. Several components of advance care planning apropos health deterioration and conflicts are discussed. Several aspects of EOL care, especially palliative nursing care, are analysed using research evidence, established nursing and palliative care standards, and the Australian EOL CPGs. Full article

Tranexamic acid (TXA) effectively reduces bleeding in women with postpartum hemorrhage (PPH) in hospital settings. To guide policies and practices, this rapid scoping review undertaken by two reviewers aimed to examine how TXA is utilized in lower-level maternity care settings in low-resource settings. Articles were searched in EMBASE, MEDLINE, Emcare, the Maternity and Infant Care Database, the Joanna Briggs Institute Evidence-Based Practice Database, and the Cochrane Library from January 2011 to September 2021. We included non-randomized and randomized research looking at the feasibility, acceptability, and health system implications in low- and lower-middle-income countries. Relevant information was retrieved using pre-tested forms. Findings were descriptively synthesized. Out of 129 identified citations, 23 records were eligible for inclusion, including 20 TXA effectiveness studies, two economic evaluations, and one mortality modeling. Except for the latter, all the studies were conducted in lower-middle-income countries and most occurred in tertiary referral hospitals. When compared to placebo or other medications, TXA was found effective in both treating and preventing PPH during vaginal and cesarean delivery. If made available in home and clinic settings, it can reduce PPH-related mortality. TXA could be cost-effective when used with non-surgical interventions to treat refractory PPH. Capacity building of service providers appears to need time-intensive training and supportive monitoring. No studies were exploring TXA acceptability from the standpoint of providers, as well as the implications for health governance and information systems. There is a scarcity of information on how to prepare the health system and services to incorporate TXA in lower-level maternity care facilities in low-resource settings. Implementation research is critically needed to assist practitioners and decision-makers in establishing a TXA-inclusive PPH treatment package to reduce PPH-related death and disability. Full article