A critical examination of ethical decision making models

This paper critically examines both the need for, and the use of, ethical decision making models (EDMMs). This paper suggests that EDMMs focus on arriving at the correct decision but ignore the action required to implement it and are therefore incomplete. In most “accounting” circumstances, finding the right decision is not what is required. Rather, a model which provides both a sound decision and, appropriate implementation would be more useful. In trying to establish a new/different EDDM that provides for this it is argued that a biblical model exists which addresses both decision making and action. This paper aims to encourage accounting ethics education to move beyond determining the right decision and focus on taking the right action.

An exploration of clinical decision-making in mental health triage

Mental health (MH) triage is a specialist area of clinical nursing practice that involves complex decision making. The discussion in this article draws on the findings of a Ph.D. study that involved a statewide investigation of the scope of MH triage nursing practice in Victoria, Australia. Although the original Ph.D. study investigated a number of core practices in MH triage, the focus of the discussion in this article is specifically on the findings related to clinical decision making in MH triage, which have not previously been published. The study employed an exploratory descriptive research design that used mixed data collection methods including a survey questionnaire (n = 139) and semistructured interviews (n = 21). The study findings related to decision making revealed a lack of empirically tested evidence-based decision-making frameworks currently in use to support MH triage nursing practice. MH triage clinicians in Australia rely heavily on clinical experience to underpin decision making and have little of knowledge of theoretical models for practice, such as methodologies for rating urgency. A key recommendation arising from the study is the need to develop evidence-based decision-making frameworks such as clinical guidelines to inform and support MH triage clinical decision making.

Haemodynamic instability after cardiac surgery: nurses` perceptions of clinical decision-making

Background. Cardiac surgical patients are distinguished by their potential for instability in the early postoperative period, highly invasive haemodynamic monitoring technologies and unique clinical presentations as a result of undergoing cardiopulmonary bypass. Little is known about nurses’ perceptions of assuming responsibility for such patients. An nderstanding of nurses’ perceptions may identify areas of practice that can be improved and assist in determining the adequacy of current decision supports.

Aim. The aim of this study was to describe critical care nurses’ perceptions of assuming responsibility for the nursing management of cardiac patients in the initial two-hour postoperative period. Design. An exploratory descriptive study based on naturalistic decision-making.

Methods. Thirty-eight nurses were interviewed immediately following a two-hour observation of their clinical practice. Content analysis and a systematic thematic analysis process called ‘Framework’ were used to analyse the interview transcripts.

Results. Nurses described their perceptions of managing patients in terms of how they felt about making decisions for complex cardiac surgical patients and in terms of how clinical processes unique to the admission phase impacted their decision-making. Nurses felt either daunted or stimulated and challenged when making decisions. Nurses identified handover from anaesthetists, settling in procedures and forms of
collegial assistance as important processes that impacted their decision-making.

Conclusion. Nurses’ previous experiences with similar patients influenced how they felt about making decisions during the initial two-hour postoperative period, but did not alter their views about processes important for patient safety during this time. Relevance to clinical practice. Feelings expressed by nurses in this study highlight the need for clinical supervision and appropriate allocation of resources during the immediate recovery period after cardiac surgery. Nurses identified ways to improve clinical processes that impacted their decision-making during the immediate recovery of cardiac surgical patients.

Decisions, decisions, decisions : an exploration of clinical decision-making in mental health triage

This paper presents the findings of a project that investigated mental health triage/duty/intake practices across the five community mental health agencies of The Alfred Hospital, Melbourne. The overall aim of the project was to work collaboratively with clinicians to further develop the quality and consistency of mental health triage, duty, and intake clinical practice. The project was designed to facilitate the expansion of the mental health triage knowledge base, and thus contribute to the further development of triage clinical practice. One of the unique aspects of the project was its triangulation across the adult triage service (acute), the two Continuing Care Teams, and the specialist psychiatric services such as the Child and Adolescent Mental Health Service, the Homeless and Outreach Psychiatric Service, and the Mobile Aged Psychiatric Service. The project employed focus group method to collect in-depth, qualitative data. A series of nine focus groups were conducted at each site, which concentrated on eliciting data on the core areas of mental health triage practice such as telephone consultation skills, mental status examination, risk assessment, decision-making, negotiation, crisis assessment, secondary consultation, and documentation. The investigation produced a considerable amount of high quality, in-depth data that was analysed using content analysis methods. The focus of this paper is on presenting the data on clinical decision-making that was raised through the project.

The ethics of surrogate decision making in medicine : autonomy, paternalism, or a different approach?

Knowing who to involve in treatment decisions when a patient is incapacitated has been the subject of discussion in bioethical, health law and clinical research. The major issues tend to revolve around the tension between exercising a degree of medical paternalism and respecting patient autonomy. Patients are encouraged to exert their autonomy even when they may not be capable of doing so, by means of surrogate consent or advanced directives. While liberal concepts of autonomy are exemplified in western bioethics and legal systems, clinically these decisions remain difficult, and input from medical professionals is sought, raising the issue of paternalism. A framework of bioethics, which places the patient in a relational context rather than a strictly autonomous one, may be a more helpful way of deliberating these difficult decisions

‘Moral luck’ and the question of autonomy, choice, and control in end-of-life decision making

It is commonly assumed that, in the realm of ethical decision making at the end-of-life, ‘luck’ and ‘risk’ do not intrude. Nonetheless ‘moral luck’ (where happenstance makes a moral difference) does intrude and can have an unanticipated impact on the ultimate moral outcomes of end-of-life care. In the interests of upholding the ethical standards of end-of-life care, healthcare providers have increasingly relied on ethical principlism as a rational decision-guiding frame in the sincere belief that such an approach will enable patient selfdetermination and control over treatment decisions when needing end-of-life care. Due to contextual variables and associated uncertainties in end-of-life care, however, the intended moral outcomes of appeals to commonly accepted ethical principles (in particular the principle of autonomy) are not always realized. What is not always appreciated is that whether ‘good’ or ‘bad’ moral outcomes are achieved can be as much a matter of chance as of choice. This essay explores the relevance and possible implications of moral luck in end-of-life decision making and care. A key conclusion of the paper is that the notion of moral luck needs to be taken seriously in end-of-life care contexts since it can have an unanticipated impact on the outcomes of the decisions that are made and thereby on the moral interests of patients facing the end of their lives.

Critically impaired infants and end of life decision making : resource allocation and difficult decisions

Decisions to withdraw or withhold life-sustaining treatment are contentious, and offer difficult moral dilemmas to both medical practitioners and the judiciary. This issue is exacerbated when the patient is unable to exercise autonomy and is entirely dependent on the will of others.This book focuses on the legal and ethical complexities surrounding end of life decisions for critically impaired and extremely premature infants. Neera Bhatia explores decisions to withdraw or withhold life-sustaining treatment from critically impaired infants and addresses the controversial question, which lives are too expensive to treat? Bringing to bear such key issues as clinical guidance, public awareness, and resource allocation, the book provides a rational approach to end of life decision making, where decisions to withdraw or withhold treatment may trump other competing interests.The book will be of great interest and use to scholars and students of bioethics, medical law, and medical practitioners.

Brain substrates of social decision-making in dual diagnosis: cocaine dependence and personality disorders

Cocaine dependence frequently co-occurs with personality disorders, leading to increased interpersonal problems and greater burden of disease. Personality disorders are characterised by patterns of thinking and feeling that divert from social expectations. However, the comorbidity between cocaine dependence and personality disorders has not been substantiated by measures of brain activation during social decision-making. We applied functional magnetic resonance imaging to compare brain activations evoked by a social decision-making task-the Ultimatum Game-in 24 cocaine dependents with personality disorders (CDPD), 19 cocaine dependents without comorbidities and 19 healthy controls. In the Ultimatum Game participants had to accept or reject bids made by another player to split monetary stakes. Offers varied in fairness (in fair offers the proposer shares ~50 percent of the money; in unfair offers the proposer shares <30 percent of the money), and participants were told that if they accept both players get the money, and if they reject both players lose it. We contrasted brain activations during unfair versus fair offers and accept versus reject choices. During evaluation of unfair offers CDPD displayed lower activation in the insula and the anterior cingulate cortex and higher activation in the lateral orbitofrontal cortex and superior frontal and temporal gyri. Frontal activations negatively correlated with emotion recognition. During rejection of offers CDPD displayed lower activation in the anterior cingulate cortex, striatum and midbrain. Dual diagnosis is linked to hypo-activation of the insula and anterior cingulate cortex and hyper-activation of frontal-temporal regions during social decision-making, which associates with poorer emotion recognition.

Use of aggregation functions in decision making

A key component of many decision making processes is the aggregation step, whereby a set of numbers is summarised with a single representative value. This research showed that aggregation functions can provide a mathematical formalism to deal with issues like vagueness and uncertainty, which arise naturally in various decision contexts.

The study protocol of: 'initiating end of life care in stroke: clinical decision- making around prognosis'

 Background: The initiation of end of life care in an acute stroke context should be focused on those patients and families with greatest need. This requires clinicians to synthesise information on prognosis, patterns (trajectories) of dying and patient and family preferences. Within acute stroke, prognostic models are available to identify risks of dying, but variability in dying trajectories makes it difficult for clinicians to know when to commence palliative interventions. This study aims to investigate clinicians’ use of different types of evidence in decisions to initiate end of life care within trajectories typical of the acute stroke population.
Methods/design: This two-phase, mixed methods study comprises investigation of dying trajectories in acute stroke (Phase 1), and the use of clinical scenarios to investigate clinical decision-making in the initiation of palliative care (Phase 2). It will be conducted in four acute stroke services in North Wales and North West England. Patient and public involvement is integral to this research, with service users involved at each stage.
Discussion: This study will be the first to examine whether patterns of dying reported in other diagnostic groups are transferable to acute stroke care. The strengths and limitations of the study will be considered. This research will produce comprehensive understanding of the nature of clinical decision-making around end of life care in an acute stroke context, which in turn will inform the development of interventions to further build staff knowledge, skills and confidence in this challenging aspect of acute stroke care.

Decision making in health care: limitations of the substituted judgement principle

The substituted judgement principle is often recommended as a means of promoting the self-determination of an incompetent individual when proxy decision makers are faced with having to make decisions about health care. This article represents a critical ethical analysis of this decision-making principle and describes practical impediments that serve to undermine its fundamental purpose. These impediments predominantly stem from the informality associated with the application of the substituted judgement principle. It is recommended that the principles upon which decisions are made about health care for another person should be transparent to all those involved in the process. Furthermore, the substituted judgement principle requires greater rigour in its practical application than currently tends to be the case. It may be that this principle should be subsumed as a component of advance directives in order that it fulfils its aim of serving to respect the self-determination of incompetent individuals.

Naturalistic decision making: a model to overcome methodological challenges in the study of critical care nurses` decision making about patients` hemodynamic status

The quality of critical care nurses' decision making about patients' hemodynamic status in the immediate period after cardiac surgery is important for the patients' well-being and, at times, survival. The way nurses respond to hemodynamic cues varies according to the nurses' skills, experiences, and knowledge. Variability in decisions is also associated with the inherent complexity of hemodynamic monitoring. Previous methodological approaches to the study of hemodynamic assessment and treatment decisions have ignored the important interplay between nurses, the task, and the environment in which these decisions are made. The advantages of naturalistic decision making as a framework for studying the manner in which nurses make decisions are presented.

The influence of patient complexity and nurses` experience on haemodynamic decision-making following cardiac surgery

Critical care nurses’ haemodynamic decision-making in the immediate postoperative cardiac surgical context is complex. To optimise patient outcomes, nurses of varying levels of experience are required to make complex decisions rapidly and accurately. In a dynamic clinical context such as critical care, the quality of such decision-making is likely to vary considerably. The aim of this study was to describe variability of nurses’ haemodynamic decision-making in the 2-hour period after cardiac surgery as a function of interplay between decision complexity, nurses’ levels of experience, and the support provided. A descriptive study based on naturalistic decision-making was used. Data were collected using continuous non-participant observation of clinical practice for a 2-hour period and follow-up interview. Purposive sampling was used to recruit 38 nurses for inclusion in the study. The quality of nurses’ decision-making was influenced by interplay between the complexity of patients’ haemodynamic presentations, nurses’ levels of cardiac surgical intensive care experience, and the form of decision support provided by nursing colleagues. Two factors specifically influenced decision-making quality: nurses’ utilisation of evidence for practice and the experience levels of both nurses and their colleagues. The findings have implications for staff resourcing decisions and postoperative patient management, and may be used to inform nurses’ professional development and education.