Medical Uncertainty Revisited

Fox, Renée C.

doi:10.4135/9781848608412.n26

Cited by 164 publications

(107 citation statements)

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“…It is humanly impossible to master the constantly emerging volume of knowledge and skills that comprises current clinical knowledge. This knowledge base also has gaps and limitations: it is often not clear whether we are unaware of existing information or whether that information does not exist (Fox, 2000). So where uncertainty exists, not everyone can get it .…”

Section: Learning How To Make the Right Decision Fastmentioning

confidence: 99%

Student life - Learning how to make the right decision fast

Adderley

2015

Nursing Standard

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Section: Learning How To Make the Right Decision Fastmentioning

confidence: 99%

Student life - Learning how to make the right decision fast

Adderley

2015

Nursing Standard

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“…This uncertainty about prognosis for individual patients is inherent to all clinical practice and can be difficult to discuss with patients. 132,133 Coping with this fundamental uncertainty can be compounded by other uncertainties such as lack of knowledge of the patient, which we will discuss later. Our data suggest that health professionals vary in terms of their recognition and understanding of clinical uncertainty about individual patients.…”

Section: The Timing Of a Do-not-attempt-cardiopulmonary-resuscitationmentioning

confidence: 99%

“…Uncertainty is recognised as inherent to clinical practice 133,[144][145][146] particularly when trying to determine prognosis at the individual patient level. Clinicians have to make DNACPR decisions despite this inherent uncertainty.…”

Section: Stakeholder Engagementmentioning

confidence: 99%

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

Perkins

Griffiths

George

et al. 2016

Health Serv Deliv Res

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BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…Les défis y sont nombreux. Parmi eux, la diversification des populations au sein de l'hôpital (associée aux mouvements migratoires et à la mondialisation) ; davantage encore la pluralité de normes et de valeurs qui accompagnent cette diversité (notre propos) ; mais aussi l'évolution des situations cliniques en lien avec les progrès de la médecine (Fox 2003 ;Fortin et Maynard 2012) ; la croissance des pathologies chroniques complexes 3. Le majoritaire étant celui qui définit la norme dans un milieu donné (Bourgeault 2004).…”

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Conflits et reconnaissance dans l’espace social de la clinique

Fortin

2014

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L’espace clinique hospitalier est un lieu de rencontre pluriel entre soignants et soignés, entre bien-portants et souffrants, entre migrants et non-migrants, entre minoritaires et majoritaires d’appartenances diverses (origines, statut, confession). Cette rencontre peut être imaginée comme un moment de négociation et parfois de heurts par lequel se dessine notre société en évolution. À partir d’une étude ethnographique menée au cours des dernières années dans trois métropoles cosmopolites canadiennes, il sera question de l’hôpital comme acteur dans la ville et de la relation soignant/soigné (famille) en contexte pluriel. Les pratiques quotidiennes et plus largement l’espace social de la clinique deviendront autant de matériaux pour discuter la reconnaissance (ou non) de l’Autre – en l’occurrence le soigné (et sa famille) – comme acteur à part entière dans l’espace clinique et le conflit comme témoin de la négociation dans cet espace. L’examen des conditions (structurelles et situationnelles) qui favorisent l’émergence de conflits permettra à son tour de mieux cerner les rapports qu’entretiennent les cliniciens avec l’environnement pluriel de la clinique et la diversité des normes et des valeurs (clinicien/usager) qu’on peut y retrouver. Une réflexion sur les conditions d’émergence d’une normativité plurielle sera proposée en conclusion. Nous réitèrerons l’intérêt de l’hôpital au quotidien, comme lieu anthropologique percutant, pour saisir un social toujours en devenir.

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Medical Uncertainty Revisited

Cited by 164 publications

References 0 publications

Student life - Learning how to make the right decision fast

Student life - Learning how to make the right decision fast

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

Conflits et reconnaissance dans l’espace social de la clinique

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