Understanding and Characterizing Shared Decision-Making and Behavioral Intent in Medical Uncertainty

Applying Theoretical Constructs to Address Medical Uncertainty Situations involving medical reasoning usually include some level of medical uncertainty. Despite the identification of shared decision-making (SDM) as an effective technique, it has been observed that the likelihood of physicians and patients engaging in shared decision making is lower in those situations where it is most needed; specifically in circumstances of medical uncertainty. Having identified shared decision making as an effective, yet often a neglected approach to resolving a lack of information exchange in situations involving medical uncertainty, the next step is to determine the way(s) in which SDM can be integrated and the supplemental processes that may facilitate its integration. SDM involves unique types of communication and relationships between patients and physicians. Therefore, it is necessary to further understand and incorporate human behavioral elements - in particular, behavioral intent - in order to successfully identify and realize the potential benefits of SDM. This paper discusses the background and potential interaction between the theories of shared decision-making, medical uncertainty, and behavioral intent. Identifying Shared Decision-Making Elements in Medical Encounters Dealing with Uncertainty A recent summary of the state of medical knowledge in the U.S. reported that nearly half (47%) of all treatments were of unknown effectiveness, and an additional 7% involved an uncertain tradeoff between benefits and harms. Shared decision-making (SDM) was identified as an effective technique for managing uncertainty when two or more parties were involved. In order to understand which of the elements of SDM are used most frequently and effectively, it is necessary to identify these key elements, and understand how these elements related to each other and the SDM process. The elements identified through the course of the present research were selected from basic principles of the SDM model and the “Data, Information, Knowledge, Wisdom” (DIKW) Hierarchy. The goal of this ethnographic research was to identify which common elements of shared decision-making patients are most often observed applying in the medical encounter. The results of the present study facilitated the understanding of which elements patients were more likely to exhibit during a primary care medical encounter, as well as determining variables of interest leading to more successful shared decision-making practices between patients and their physicians. Understanding Behavioral Intent to Participate in Shared Decision-Making in Medically Uncertain Situations Objective: This article describes the process undertaken to identify and validate behavioral and normative beliefs and behavioral intent of men between the ages of 45-70 with regard to participating in shared decision-making in medically uncertain situations. This article also discusses the preliminary results of the aforementioned processes and explores potential future uses of this information which may facilitate greater understanding, efficiency and effectiveness of doctor-patient consultations.Design: Qualitative Study using deductive content analysisSetting: Individual semi-structure patient interviews were conducted until data saturation was reached. Researchers read the transcripts and developed a list of codes.Subjects: 25 subjects drawn from the Philadelphia community.Measurements: Qualitative indicators were developed to measure respondents’ experiences and beliefs related to behavioral intent to participate in shared decision-making during medical uncertainty. Subjects were also asked to complete the Krantz Health Opinion Survey as a method of triangulation.Results: Several factors were repeatedly described by respondents as being essential to participate in shared decision-making in medical uncertainty. These factors included past experience with medical uncertainty, an individual’s personality, and the relationship between the patient and his physician.Conclusions: The findings of this study led to the development of a category framework that helped understand an individual’s needs and motivational factors in their intent to participate in shared decision-making. The three main categories include 1) an individual’s representation of medically uncertainty, 2) how the individual copes with medical uncertainty, and 3) the individual’s behavioral intent to seek information and participate in shared decision-making during times of medically uncertain situations.

A group decision-making methodology with incomplete individual beliefs applied to e-Democracy

We consider the situation where there are several alternatives for investing a quantity of money to achieve a set of objectives. The choice of which alternative to apply depends on how citizens and political representatives perceive that such objectives should be achieved. All citizens with the right to vote can express their preferences in the decision-making process. These preferences may be incomplete. Political representatives represent the citizens who have not taken part in the decision-making process. The weight corresponding to political representatives depends on the number of citizens that have intervened in the decision-making process. The methodology we propose needs the participants to specify for each alternative how they rate the different attributes and the relative importance of attributes. On the basis of this information an expected utility interval is output for each alternative. To do this, an evidential reasoning approach is applied. This approach improves the insightfulness and rationality of the decision-making process using a belief decision matrix for problem modeling and the Dempster?Shafer theory of evidence for attribute aggregation. Finally, we propose using the distances of each expected utility interval from the maximum and the minimum utilities to rank the alternative set. The basic idea is that an alternative is ranked first if its distance to the maximum utility is the smallest, and its distance to the minimum utility is the greatest. If only one of these conditions is satisfied, a distance ratio is then used.

European Union and its member states as a collective actor in WTO decision-making process. ACES Cases No. 2010.3

This paper will outline and analyze the decision-making process in WTO matters. First, the players of the decision-making process -- the Council of the European Union (Council), the Trade Policy Committee, the Commission, and the European Parliament -- will be examined. Then the distinction will be made between decision-making in initiating WTO disputes and decision-making conducting trade agreement negotiations in the WTO. Then, decision-making practices in WTO matters will be assessed against constitutional principles of transparency, accountability, and legitimacy. After this assessment, conclusions will be drawn.

Political Decision-Making in Switzerland. The Consensus Model under Pressure

This in-depth study of the decision-making processes of the early 2000s shows that the Swiss consensus democracy has changed considerably. Power relations have transformed, conflict has increased, coalitions have become more unstable and outputs less predictable. Yet these challenges to consensus politics provide opportunities for innovation.

Household decision making : an exploratory study /

"This study is designed to gain insights into various aspects of family decision making. Specifically, the study examines the prevalance of autonomous versus joint decision making, the incidence of conflict in joint decision making, and the tactics used by individual household members in resolving conflict."

Virtual training environments to improve train driver's crisis decision making

This paper reports on a current research project in which virtual reality simulators are being investigated as a means of simulating hazardous Rail work conditions in order to allow train drivers to practice decision-making under stress. When working under high stress conditions train drivers need to move beyond procedural responses into a response activated through their own problem-solving and decision-making skills. This study focuses on the use of stress inoculation training which aims to build driver’s confidence in the use of new decision-making skills by being repeatedly required to respond to hazardous driving conditions. In particular, the study makes use of a train cab driving simulator to reproduce potentially stress inducing real-world scenarios. Initial pilot research has been undertaken in which drivers have experienced the training simulation and subsequently completed surveys on the level of immersion experienced. Concurrently drivers have also participated in a velocity perception experiment designed to objectively measure the fidelity of the virtual training environment. Baseline data, against which decision-making skills post training will be measured, is being gathered via cognitive task analysis designed to identify primary decision requirements for specific rail events. While considerable efforts have been invested in improving Virtual Reality technology, little is known about how to best use this technology for training personnel to respond to workplace conditions in the Rail Industry. To enable the best use of simulators for training in the Rail context the project aims to identify those factors within virtual reality that support required learning outcomes and use this information to design training simulations that reliably and safely train staff in required workplace accident response skills.

Strategic decision making in small businesses:implications for strategic flexibility and strategic adaptation

Strategic decision making (SDM) in a small business is an informal, highly personalised cognitive process which is emergent in nature. SDM determines the extent to which decision makers generate innovative decision-making options, and is therefore critical in order for small businesses to achieve strategic flexibility to enable strategic adaptation to turbulent environments. By examining SDM in small businesses, this research has the potential to address a major criticism of the extant literature in that it has been pre-occupied with measuring the formality of strategic planning and has neglected the informal, highly personalised and cognitive nature of strategic decision making in a small businesses.

Expert System for Decision-Making Problem in Economics

An expert system (ES) is a class of computer programs developed by researchers in artificial intelligence. In essence, they are programs made up of a set of rules that analyze information about a specific class of problems, as well as provide analysis of the problems, and, depending upon their design, recommend a course of user action in order to implement corrections. ES are computerized tools designed to enhance the quality and availability of knowledge required by decision makers in a wide range of industries. Decision-making is important for the financial institutions involved due to the high level of risk associated with wrong decisions. The process of making decision is complex and unstructured. The existing models for decision-making do not capture the learned knowledge well enough. In this study, we analyze the beneficial aspects of using ES for decision- making process.

Mental health pharmacists views on shared decision-making for antipsychotics in serious mental illness

Background People diagnosed with serious mental illnesses (SMIs) such as schizophrenia and bipolar affective disorder are frequently treated with antipsychotics. National guidance advises the use of shared decision-making (SDM) in antipsychotic prescribing. There is currently little data on the opinions of health professionals on the role of SDM. Objective To explore the views and experiences of UK mental health pharmacists regarding the use of SDM in antipsychotic prescribing in people diagnosed with SMI. Setting The study was conducted by interviewing secondary care mental health pharmacists in the UK to obtain qualitative data. Methods Semi-structured interviews were recorded. An inductive thematic analysis was conducted using the method of constant comparison. Main outcome measure Themes evolving from mental health pharmacists on SDM in relation to antipsychotic prescribing in people with SMI. Results Thirteen mental health pharmacists were interviewed. SDM was perceived to be linked to positive clinical outcomes including adherence, service user satisfaction and improved therapeutic relations. Despite more prescribers and service users supporting SDM, it was not seen as being practised as widely as it could be; this was attributed to a number of barriers, most predominantly issues surrounding service user’s lacking capacity to engage in SDM and time pressures on clinical staff. The need for greater effort to work around the issues, engage service users and adopt a more inter-professional approach was conveyed. Conclusion The mental health pharmacists support SDM for antipsychotic prescribing, believing that it improves outcomes. However, barriers are seen to limit implementation. More research is needed into overcoming the barriers and measuring the benefits of SDM, along with exploring a more inter-professional approach to SDM.

Adaptív döntéshozatal a beszállítóválasztásban = Adaptive Decision-making in Supplier Selection

Herbert Simon, a korlátozott racionalitás elméletének megalkotója szerint a döntéshozatalunk hatékonyságát az határozza meg, hogy korlátozott kognitív kapacitásaink birtokában milyen stratégiákkal birkózunk meg a komplex környezet kihívásaival. Az erre az elméletre építő kutatások egyik alapvetése, hogy az egyéni problémamegoldási folyamat helyzetspecifikus és ez az idomulás kulcsfontosságú az eredményességben és hatékonyságban. A döntéshozó rendelkezik egy „adaptív szerszámosládával”, amelyből a megfelelő helyzetekben a megfelelő döntési eljárásokat választja. A tanulmányban a szerző egy kvalitatív kutatás eredményeire építve, a beszállítóválasztás példáján keresztül mutat be lehetséges válaszokat a keveset kutatott kérdésre: hogyan működik az adaptivitás folyamata? A tanulmány a döntési helyzethez való alkalmazkodás kialakulását vizsgálja a döntési folyamatok kognitív szintjén. ______ Herbert Simon, the author of theory of bounded rationality claimed that the results of our decision-making is defined by the approprietness of strategies with which we handle the complexity of the environment with our bounded cognitive capacities. One of the main issues or research programs building on this theory is that problem solving is situation-specific, and the adjustment of strategies to actual situational factors is crucial for the effectiveness and efficiency of decision-making. The decision-maker possesses an „adaptive toolbox”, from which he chooses the right decision tools in the right situations. The author, based on the findnings of a qualitative study, presents possible answers to the not well-elaborated question: how does the process of adaptivity work? Forming of an adaptive mechanism is in the focus.

Individual decision-making by top executives as a valuable resource for strategic management – A resource-based view and dynamic capability approach

Strategy is highly important for organisational success and the achievement of competitive advantage. Strategy is dynamic and it depends on accurate individual decision-making from medium and high-level managers and executives. Since managers always formulate strategy, its formulation depends mostly on their assertive decisions. Making good decisions is a complex task, even more in today’s business world where a large quantity of information and a dynamic environment forces people to decide without having complete information. As Shafir, Simonson, & Tversky (1993) point out, "the making of decisions, both big and small, is often difficult because of uncertainty and conflict". In this paper the author will explain a basic theoretical framework about top manager's individual decision-making, showing how complex the process of making high-impact decisions is; then, he will compare this theory with one of the most important streams in strategic management, the Resource-Based View (RBV) of the firm. Finally, within the context of individual decision-making and the RBV stream, the author will show how individual decision makers in top management positions constitute a valuable, rare, non-imitable and non-substitutable resource that provides sustained competitive advantage.

A fresh look at decision making in international investment choices: Firm international coherence and home-host country relatedness

Understanding how decisions for international investments are made and how this affects the overall pattern of investments and firm’s performance is of particular importance both in strategy and international business research. This dissertation introduced first home-host country relatedness (HHCR) as the degree to which countries are efficiently combined within the investment portfolios of firms. It theorized and demonstrated that HHCR will vary with the motivation for investments along at least two key dimensions: the nature of foreign investments and the connectedness of potential host countries to the rest of the world. Drawing on cognitive psychology and decision-making research, it developed a theory of strategic decision making proposing that strategic solutions are chosen close to a convenient anchor. Building on research on memory imprinting, it also proposed that managers tend to rely on older knowledge representation. In the context of international investment decisions, managers use their home countries as an anchor and are more likely to choose as a site for foreign investments host countries that are ‘close’ to the home country. These decisions are also likely to rely more strongly on closeness to time invariant country factors of historic and geographic nature rather than time-variant institutions. Empirical tests using comprehensive investments data by all public multinational companies (MNC) worldwide, or over 15,000 MNCs with over half a million subsidiaries, support the claims. Finally, the dissertation introduced the concept of International Coherence (IC) defined as the degree to which an MNE’s network comprises countries that are related. It was hypothesized that maintaining a high level of coherence is important for firm performance and will enhance it. Also, the presence of international coherence mitigates some of the negative effects of unrelated product diversification. Empirical tests using data on foreign investments of over 20,000 public firms, while also developing a home-host country relatedness index for up to 24,300 home-host pairs, provided support for the theory advanced.

Decision-Making in the Primate Brain

Making decisions is fundamental to everything we do, yet it can be impaired in various disorders and conditions. While research into the neural basis of decision-making has flourished in recent years, many questions remain about how decisions are instantiated in the brain. Here we explored how primates make abstract decisions and decisions in social contexts, as well as one way to non-invasively modulate the brain circuits underlying decision-making. We used rhesus macaques as our model organism. First we probed numerical decision-making, a form of abstract decision-making. We demonstrated that monkeys are able to compare discrete ratios, choosing an array with a greater ratio of positive to negative stimuli, even when this array does not have a greater absolute number of positive stimuli. Monkeys’ performance in this task adhered to Weber’s law, indicating that monkeys—like humans—treat proportions as analog magnitudes. Next we showed that monkeys’ ordinal decisions are influenced by spatial associations; when trained to select the fourth stimulus from the bottom in a vertical array, they subsequently selected the fourth stimulus from the left—and not from the right—in a horizontal array. In other words, they begin enumerating from one side of space and not the other, mirroring the human tendency to associate numbers with space. These and other studies confirmed that monkeys’ numerical decision-making follows similar patterns to that of humans, making them a good model for investigations of the neurobiological basis of numerical decision-making.

We sought to develop a system for exploring the neuronal basis of the cognitive and behavioral effects observed following transcranial magnetic stimulation, a relatively new, non-invasive method of brain stimulation that may be used to treat clinical disorders. We completed a set of pilot studies applying offline low-frequency repetitive transcranial magnetic stimulation to the macaque posterior parietal cortex, which has been implicated in numerical processing, while subjects performed a numerical comparison and control color comparison task, and while electrophysiological activity was recorded from the stimulated region of cortex. We found tentative evidence in one paradigm that stimulation did selectively impair performance in the number task, causally implicating the posterior parietal cortex in numerical decisions. In another paradigm, however, we manipulated the subject’s reaching behavior but not her number or color comparison performance. We also found that stimulation produced variable changes in neuronal firing and local field potentials. Together these findings lay the groundwork for detailed investigations into how different parameters of transcranial magnetic stimulation can interact with cortical architecture to produce various cognitive and behavioral changes.

Finally, we explored how monkeys decide how to behave in competitive social interactions. In a zero-sum computer game in which two monkeys played as a shooter or a goalie during a hockey-like “penalty shot” scenario, we found that shooters developed complex movement trajectories so as to conceal their intentions from the goalies. Additionally, we found that neurons in the dorsolateral and dorsomedial prefrontal cortex played a role in generating this “deceptive” behavior. We conclude that these regions of prefrontal cortex form part of a circuit that guides decisions to make an individual less predictable to an opponent.

Social Decision-Making in Bonobos and Chimpanzees

Humans are natural politicians. We obsessively collect social information that is both observable (e.g., about third-party relationships) and unobservable (e.g., about others’ psychological states), and we strategically employ that information to manage our cooperative and competitive relationships. To what extent are these abilities unique to our species, and how did they evolve? The present dissertation seeks to contribute to these two questions. To do so, I take a comparative perspective, investigating social decision-making in humans’ closest living relatives, bonobos and chimpanzees. In Chapter 1, I review existing literature on theory of mind—or the ability to understand others’ psychological states—in these species. I also present a theoretical framework to guide further investigation of social cognition in bonobos and chimpanzees based on hypotheses about the proximate and ultimate origins of their species differences. In Chapter 2, I experimentally investigate differences in the prosocial behavior of bonobos and chimpanzees, revealing species-specific prosocial motivations that appear to be less flexible than those exhibited by humans. In Chapter 3, I explore through decision-making experiments bonobos’ ability to evaluate others based on their prosocial or antisocial behavior during third-party interactions. Bonobos do track the interactions of third-parties and evaluate actors based on these interactions. However, they do not exhibit the human preference for those who are prosocial towards others, instead consistently favoring an antisocial individual. The motivation to prefer those who demonstrate a prosocial disposition may be a unique feature of human psychology that contributes to our ultra-cooperative nature. In Chapter 4, I investigate the adaptive value of social cognition in wild primates. I show that the recruitment behavior of wild chimpanzees at Gombe National Park, Tanzania is consistent with the use of third-party knowledge, and that those who appear to use third-party knowledge receive immediate proximate benefits. They escape further aggression from their opponents. These findings directly support the social intelligence hypothesis that social cognition has evolved in response to the demands of competing with one’s own group-mates. Thus, the studies presented here help to better characterize the features of social decision-making that are unique to humans, and how these abilities evolved.

Renal palliative care – where to after the PACKS study?

The PAlliative Care in chronic Kidney diSease study (PACKS study) is examining quality of life, decision making and decisional conflict, costs and mortality in patients with advanced chronic kidney disease who have opted for palliative care. It is also exploring the impact of the decision on the quality of life of carers. The study includes adult patients with end stage (stage 5) chronic kidney disease who have opted for palliative care, adult carers of these patients and renal physicians/clinical nurse specialists who have experience of treating patients with end stage chronic kidney disease who have opted for palliative care.
Early initial findings relate to clinician perspectives on patient decisional conflict, in making complex decisions between dialysis and conservative management. Interviews were conducted with nephrologists and clinical nurse specialists across 10 renal centres in the UK. Themes with associated subthemes include “Frequent changing of mind regarding treatment options,” “A paternalistic approach to decision-making and “Intricacy of the decision”. These findings will be presented and recommendations for future research and education made. Clinicians need to take a more patient centered approach to decision-making. Interventions aimed at increasing understanding of renal disease and its treatments may reduce decisional conflict and raise decisional quality but require testing in the renal specialty.