Retrospective study of doctors' "end of life decisions" in caring for mentally handicapped people in institutions in The Netherlands.

OBJECTIVES: To gain insight into the reasons behind and the prevalence of doctors'' decisions at the end of life that might hasten a patient''s death ("end of life decisions") in institutions caring for mentally handicapped people in the Netherlands, and to describe important aspects of the decisions making process. DESIGN: Survey of random sample of doctors caring for mentally handicapped people by means of self completed questionnaires and structured interviews. SUBJECTS: 89 of the 101 selected doctors completed the questionnaire. 67 doctors had taken an end of life decision and were interviewed about their most recent case. MAIN OUTCOME MEASURES: Prevalence of end of life decisions; types of decisions; characteristics of patients; reasons why the decision was taken; and the decision making process. RESULTS: The 89 doctors reported 222 deaths for 1995. An end of life decision was taken in 97 cases (44%); in 75 the decision was to withdraw or withhold treatment, and in 22 it was to relieve pain or symptoms with opiates in dosages that may have shortened life. In the 67 most recent cases with an end of life decision the patients were mostly incompetent (63) and under 65 years old (51). Only two patients explicitly asked to die, but in 23 cases there had been some communication with the patient. In 60 cases the doctors discussed the decision with nursing staff and in 46 with a colleague. CONCLUSIONS: End of life decisions are an important aspect of the institutionalised care of mentally handicapped people. The proportion of such decisions in the total number of deaths is similar to that in other specialties. However, the discussion of such decisions is less open in the care of mental handicap than in other specialties. Because of distinctive features of care in this specialty an open debate about end of life decisions should not be postponed.     

The practitioner,the patient and resistance to change: recent ideas on compliance.

Despite the explosion of research into the effect of medical advice on patient behaviour, only about 50% of patients comply with long-term drug regimens. And when it comes to changes in lifestyle, the percentage of patients who comply with medical advice often falls to single figures. Review articles on compliance have traditionally concentrated on factors that make it easier for patients to adhere to medical advice. However, recent articles urge clinicians to be more understanding of the wider implications of compliance in their patients'' lives. This article focuses on how clinicians'' consulting methods can affect patients'' behaviour. Specifically, the authors consider the patient-centred clinical method as well as insights from and consulting techniques pioneered in the addictions field that can help to bring ambivalent patients closer to decisions about change. Instead of seeing resistance to change as rooted entirely in the patient, the authors view it as stemming partly from the way clinicians talk to patients. An advice-giving approach is usually inadequate to motivate people to embark on major lifestyle changes. Instead, the authors propose a negotiation-based framework that harnesses patients'' intrinsic motivation to make their own decisions. This approach also promotes clinicians'' acceptance of patients'' decisions, even if these decisions run counter to current medical wisdom.     

Quorum responses and consensus decision making

Animal groups are said to make consensus decisions when group members come to agree on the same option. Consensus decisions are taxonomically widespread and potentially offer three key benefits: maintenance of group cohesion, enhancement of decision accuracy compared with lone individuals and improvement in decision speed. In the absence of centralized control, arriving at a consensus depends on local interactions in which each individual''s likelihood of choosing an option increases with the number of others already committed to that option. The resulting positive feedback can effectively direct most or all group members to the best available choice. In this paper, we examine the functional form of the individual response to others'' behaviour that lies at the heart of this process. We review recent theoretical and empirical work on consensus decisions, and we develop a simple mathematical model to show the central importance to speedy and accurate decisions of quorum responses, in which an animal''s probability of exhibiting a behaviour is a sharply nonlinear function of the number of other individuals already performing this behaviour. We argue that systems relying on such quorum rules can achieve cohesive choice of the best option while also permitting adaptive tuning of the trade-off between decision speed and accuracy.     

Reciprocal altruism as a felony: Antitrust and the prisoner's dilemma

Biologist study reciprocity. Because U.S. law outlaws cooperative commercial efforts to establish and maintain cartelized prices, for almost a century lawyers and judges also have been interested in the phenomenon of reciprocity. Judges and enforcement officials have set policy based upon intuitive hunches about the likelihood of reciprocity. This law is not consistent. Older court decisions exhibit fear that reciprocity is probable, while more recent doctrine and commentary have disparaged the likelihood of successful cooperation. This antitrust dispute can be understood in game theoretic terms similar to analyses of reciprocity developed by biological theorists. Axelrod's recent research on the repeated prisoner's dilemma game provides an explanation of how cooperative pricing can evolve despite competitive adversity. This research implies both support for the older antitrust fear of collusive reciprocity as well as criticism of recent and supposedly modern skepticism about the older view. But Axelrod's research as it stands is too simplistic for the market context. Before antitrust can use it, this research must be extended to account for three factors: for the existence of more than two equally sized players, for uncertainty in players' communication, and for the manner in which firms learn their managerial strategies.     

Value theory and the best interests standard

The idea of a patient's best interests raises issues in prudential value theory–the study of what makes up an individual's ultimate (nonmoral) good or well-being. While this connection may strike a philosopher as obvious, the literature on the best interests standard reveals almost no engagement of recent work in value theory. There seems to be a growing sentiment among bioethicists that their work is independent of philosophical theorizing. Is this sentiment wrong in the present case? Does value theory make a significant difference in interpreting best interests? In pursuing this question, I begin with a quick sketch of broad kinds of value theories, identifying representatives that are plausible enough to count as contenders. I then explore what each account suggests in (1) neonatal treatment decisions, and (2) decisions for patients in persistent vegetative states. I conclude that while these accounts converge somewhat in their interpretations of best interests, they also have importantly different implications.     

Understanding of elderly patients' resuscitation preferences by physicians and nurses.

We compared the understanding by family physicians and nurses of their elderly outpatients'' preferences for cardiopulmonary resuscitation and mechanical ventilation under 3 scenarios reflecting varying qualities of life. Physicians and nurses correctly predicted patients'' treatment preferences in from 59% to 84% and 53% to 78% of cases, respectively, for the various decisions. For most decisions, neither physicians nor nurses were significantly more accurate in their predictions than expected by chance alone. Moreover, nurses and physicians did not significantly agree with one another in their predictions of patients'' preferences for any of these decisions. These results suggest that while nurses'' and physicians'' perceptions of patients'' preferences for life-sustaining treatment are not necessarily similar, neither nurses nor physicians systematically understand their elderly patients'' resuscitation preferences.     

Conflicts of interest and the evolution of decision sharing

Social animals regularly face consensus decisions whereby they choose, collectively, between mutually exclusive actions. Such decisions often involve conflicts of interest between group members with respect to preferred action. Conflicts could, in principle, be resolved, either by sharing decisions between members (‘shared decisions’) or by one ‘dominant’ member making decisions on behalf of the whole group (‘unshared decisions’). Both, shared and unshared decisions, have been observed. However, it is unclear as to what favours the evolution of either decision type. Here, after a brief literature review, we present a novel method, involving a combination of self-organizing system and game theory modelling, of investigating the evolution of shared and unshared decisions. We apply the method to decisions on movement direction. We find that both, shared and unshared, decisions can evolve without individuals having a global overview of the group''s behaviour or any knowledge about other members'' preferences or intentions. Selection favours unshared over shared decisions when conflicts are high relative to grouping benefits, and vice versa. These results differ from those of group decision models relating to activity timings. We attribute this to fundamental differences between collective decisions about modalities that are disjunct (here, space) or continuous (here, time) with respect to costs/benefits.     

北方草原牧户心理载畜率与草畜平衡生态管理途径

探讨牧户心理载畜率与草畜平衡生态管理的途径对于草原有效减畜、遏止草原退化、实现可持续发展具有重要意义。从生态学和社会科学相结合的角度,采用问卷调查、情景实验及综合分析等多种方法,探讨了北方草原牧户心理载畜率的存在、计算和影响因素,以及牧户生产决策行为特征和可能的生态管理途径。研究发现,在草甸草原、典型草原和荒漠草原,牧户行为属"有限理性",是有限理性的"生态经济人",风险规避是其基本特征,牧户生产决策表现出禀赋效应、损失厌恶、框架效应等;牧户草场所属草原类型和牲畜存栏数显著影响牧户对草场超载的认知和判断,在不同草原类型区,户主文化水平、性别、民族和是否嘎查干部等亦显著影响牧户对超载的认知和判断;需采取基于进化博弈的分步式、合作式及示范引导式的适应性减畜的生态管理途径,以实现牧户心理载畜率向生态优化载畜率的转移,实现优化牧户生产方式、减少牲畜数量、治理草原退化、北方牧区生态和牧民经济双赢的目标。     

Can male Eurasian jays disengage from their own current desire to feed the female what she wants?

Humans'' predictions of another person''s behaviour are regularly influenced by what they themselves might know or want. In a previous study, we found that male Eurasian jays (Garrulus glandarius) could cater for their female partner''s current desire when sharing food with her. Here, we tested the extent to which the males'' decisions are influenced by their own current desire. When the males'' and female''s desires matched, males correctly shared the food that was desired by both. When the female''s desire differed from their own, the males'' decisions were not entirely driven by their own desires, suggesting that males also took the female''s desire into account. Thus, the male jays'' decisions about their mates'' desires are partially biased by their own desire and might be based upon similar processes as those found in humans.     

TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

Assessment of cardiotocographs

In recent years advances in medical electronic equipment for monitoring, diagnosis and treatment of patients have led to a large increase in the number and variety of instrumentation available to the medical profession. There is a considerable amount of duplication of equipment and in the absence of readily available information buyers are unlikely to make informed decisions about the ideal instrument for their particular circumstances. One method of increasing the users' awareness is a comparative, independent assessment of equipment, with the results disseminated to the interested parties. This paper describes the essential qualities of cardiotocographs: how they are assessed as part of the UK Department of Health's evaluation programme and the measures to inform users of the latest evaluation information.     

b-Catenin and Cyclin D1: Connecting Development to Breast Cancer

b-catenin and cyclin D1 have attracted considerable attention due to their proto-oncogenic roles in human cancer. The finding of cyclin D1 as a direct target gene of b-catenin in colon cancer cells led to the assumption that cyclin D1 upregulation is pivotal to b-catenin's oncogenicity. Our recent paper shows that this is not the case; cyclin D1 dampens the oncogenicity of activated b-catenin (MMTV-DN89b-catenin). The relationships and dependencies of b-catenin and cyclin D1 point to distinct, essential and sequential roles during alveologenisis. These results support the concept that both b-catenin's and cyclin D1's actions are more sophisticated than simple acceleration of the cell cycle clock. These proteins are employed at critical junctures involving cell fate decisions that we speculate require specific types of cel cycle to traverse.     

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

Human Wagering Behavior Depends on Opponents' Faces

Research in competitive games has exclusively focused on how opponent models are developed through previous outcomes and how peoples'' decisions relate to normative predictions. Little is known about how rapid impressions of opponents operate and influence behavior in competitive economic situations, although such subjective impressions have been shown to influence cooperative decision-making. This study investigates whether an opponent''s face influences players'' wagering decisions in a zero-sum game with hidden information. Participants made risky choices in a simplified poker task while being presented opponents whose faces differentially correlated with subjective impressions of trust. Surprisingly, we find that threatening face information has little influence on wagering behavior, but faces relaying positive emotional characteristics impact peoples'' decisions. Thus, people took significantly longer and made more mistakes against emotionally positive opponents. Differences in reaction times and percent correct were greatest around the optimal decision boundary, indicating that face information is predominantly used when making decisions during medium-value gambles. Mistakes against emotionally positive opponents resulted from increased folding rates, suggesting that participants may have believed that these opponents were betting with hands of greater value than other opponents. According to these results, the best “poker face” for bluffing may not be a neutral face, but rather a face that contains emotional correlates of trustworthiness. Moreover, it suggests that rapid impressions of an opponent play an important role in competitive games, especially when people have little or no experience with an opponent.     

Collective decision‐making and fission–fusion dynamics: a conceptual framework

Sociality exists in an extraordinary range of ecological settings. For individuals to accrue the benefits associated with social interactions, they are required to maintain a degree of spatial and temporal coordination in their activities, and make collective decisions. Such coordination and decision‐making has been the focus of much recent research. However, efforts largely have been directed toward understanding patterns of collective behaviour in relatively stable and cohesive groups. Less well understood is how fission–fusion dynamics mediate the process and outcome of collective decisions making. Here, we aim to apply established concepts and knowledge to highlight the implications of fission–fusion dynamics for collective decisions, presenting a conceptual framework based on the outcome of a small‐group discussion INCORE meeting (funded by the European Community's Sixth Framework Programme). First, we discuss how the degree of uncertainty in the environment shapes social flexibility and therefore the types of decisions individuals make in different social settings. Second, we propose that the quality of social relationships and the energetic needs of each individual influence fission decisions. Third, we explore how these factors affect the probability of individuals to fuse. Fourth, we discuss how group size and fission–fusion dynamics may affect communication processes between individuals at a local or global scale to reach a consensus or to fission. Finally, we offer a number of suggestions for future research, capturing emerging ideas and concepts on the interaction between collective decisions and fission–fusion dynamics.     

Mothers,Fathers, Families,and Circumstances: Factors Affecting Children's Adjustment

The burgeoning empirical literature exploring the factors accounting for individual differences in psychological adjustment is reviewed. Many studies have shown that adjustment is largely affected by differences in the quality of parenting and parent–child relationships, the quality of the relationships between the parents, and the richness of the economic and social resources available to the family; more recent research signals the importance of congenital differences as well. Dimensions of family structure—including such factors as divorce, single parenthood, and the parents' sexual orientation—and biological relatedness between parents and children are of little or no predictive importance once the process variables are taken into account, because the same factors explain child adjustment regardless of family structure. These findings have important social and legal implications, especially in relation to decisions regarding foster care and adoption, as well as those concerning children's well-being following family dissolution.     

Historical origins of current problems in cancer control

Canada''s provinces have some of the most highly developed cancer control systems in the world, but the recent crisis in waiting times for radiotherapy has drawn attention to many weaknesses and inadequacies. Focusing on the province with the largest cancer control system, Ontario, this paper explores the historical origins of current problems in cancer control and shows that they are directly related to policy decisions made in the early years of the system. The development of cancer control in Ontario from the 1920s to the present is outlined, and the historical origins of 3 specific problems related to patient care are discussed: fragmentation of care, which has resulted from an emphasis on radiotherapy rather than comprehensive care and from tensions between the medical profession and government; variation in practice, which can be traced to the empirical origin of much cancer treatment and the slow implementation of research programs; and inequitable access to care, which can be attributed to the emphasis on geographic centralization of services. Attempts to reform Ontario''s cancer control system are unlikely to be successful unless these fundamental issues are recognized and addressed.     

A study of general practitioners' reasons for changing their prescribing behaviour.

OBJECTIVES--To explore general practitioners'' reasons for recent changes in their prescribing behaviour. DESIGN--Qualitative analysis of semistructured interviews. SETTING--General practice in south east London. SUBJECTS--A heterogeneous sample of 18 general practitioners. RESULTS--Interviewees were able to identify between two and five specific changes that had occurred in their prescribing in the preceding six months. The most frequently mentioned changes related to fluoxetine, angiotensin converting enzyme inhibitors, and the antibiotic treatment of Helicobacter pylori. Three models of change were identified: an accumulation model, in which the volume and authority of evidence were important; a challenge model, in which behaviour change followed a dramatic or conflictual clinical event; and a continuity model, in which change took place against a background of willingness to change, modulated by other factors such as cost pressures and the comprehensible therapeutic action of a drug. Behaviour change was reinforced and sustained by experiences with individual patients. CONCLUSIONS--Multiple factors are involved in general practitioners'' decisions to change their prescribing habits. Three models of change can be identified which have important implications for the design and evaluation of interventions aimed at behaviour change.     

The economic determinants of land degradation in developing countries

The following paper investigates the economic determinants of land degradation in developing countries. The main trends examined are rural households'' decisions to degrade as opposed to conserve land resources, and the expansion of frontier agricultural activity that contributes to forest and marginal land conversion. These two phenomena appear often to be linked. In many developing areas, a poor rural household''s decision whether to undertake long-term investment in improving existing agricultural land must be weighed against the decision to abandon this land and migrate to environmentally fragile areas. Economic factors play a critical role in determining these relationships. Poverty, imperfect capital markets and insecure land tenure may reinforce the tendency towards short-term time horizons in production decisions, and may bias land use decisions against long-term land management strategies. In periods of commodity booms and land speculation, wealthier households generally take advantage of their superior political and market power to ensure initial access to better quality resources, in order to capture a larger share of the resource rents. Poorer households are confined either to marginal environmental areas where resource rents are limited, or only have access to resources once they are degraded and rents dissipated.<br>Overall trends in land degradation and deforestation are examined, followed by an overview of rural households'' resource management decisions with respect to land management, frontier agricultural expansion, and migration from existing agricultural land to frontiers. Finally, the discussion focuses on the scope for policy improvements to reduce economic constraints to effective land management. <br>