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Title: Clinical Decision Making in Paramedicine Author(s) & affiliation(s): Michael Eby – McMaster University, Hamilton, ON, Canada Sandra Monteiro – McMaster University, Hamilton, ON, Canada Geoffrey Norman – McMaster University, Hamilton, ON, Canada Walter Tavares – McMaster University, Hamilton, ON, Canada Background: Paramedics are frequently required to make rapid decisions in an uncontrolled, dynamic environment, often with limited diagnostic information. In Ontario, paramedic practice is based on a set of provincial medical directives that provide diagnostic and treatment criteria. Unsupervised deviation from these directives is classified as a form of error and highly discouraged. To date, there is little known about how years of clinical experience or level of certification affect the way these medical directives are used. The purpose of this study was to examine the relationship between paramedic experience, training and accuracy of treatment decisions when faced with patients who meet and fall outside of the existing medical directives. Methods: Thirty-one participants (16 experienced / 15 novice) were recruited from two paramedic services in Ontario. “Experienced” was defined as in-practice for 5 years or more. Participants were presented with 9 scenarios; in 6 scenarios, the patient presentation fit within the existing directives, while in 3 scenarios, the patient presentation fell outside the medical directives. Multiple-choice responses were used to capture participants’ decisions to treat or not treat the patients. Responses were scored and submitted to a mixed-factorial ANOVA to evaluate differences in accuracy between case types, years of experience and level of training. Results: There was a significant effect of case type (p < 0.004). Accuracy was lower when the patient presentation did not meet the criteria of the medical directive (76.34% (CI = 67.15% to 85.53%) vs. 98.35% (CI = 96.55% to 100%) when they did. There was no effect of years of clinical practice or level of certification. Conclusion: The results suggest both novice and experienced paramedics are able to accurately apply medical directives, however, there is a significant decrease in accuracy when the patient presentation does not fit one. This variation in practice may have a significant impact on patient safety, and further research is required to determine what factors may be causing this decreased accuracy. / Thesis / Master of Science (MSc) / Paramedics work in a fast-paced, dynamic environment. The types of patients, and the situations paramedics encounter are different every day. Paramedic practice is based on a series of provincial medical directives that outline the different proceedures, medications and types of patients that can be treated. While these directives cover many of the cases paramedics encounter, there will always be cases that don’t “fit”. The purose of this study is to see if paramedics approach those types of cases in a different way, and if their years of experience or level of training change how good they are at idenfiying what patients require treatment. As there is very little paramedic specific research on this topic, this study will serve as a starting point for future research and hopefully stimulate discussion about paramedic practice, and how to support paramedics getting better at their jobs.

Energy supply security is a hot topic today. It highly influences energy market, national security and also residents’ daily lives. However, due to different aims and study strategies, definitions of energy supply security are different. In this report, it is defined as stable energy supply processes that result from good infrastructure, delivery of energy sources, carriers and services, which are sturdily controlled by effective energy policies. Prices of energy supply system are also maintained on a reasonable level over a continuous period thanks to the efficient crises assessment and management. In order to make a comprehensive research, energy situation has been deeply investigated on worldwide, EU and Swedish levels, respectively. Results from these investments obviously certify that due to the big amount of populations, there are significant imbalances between energy supply and demands in developing countries. To make things better, these imbalances don’t exist in developed world, like EU Members including Sweden because of applications of advanced technologies and wide utilizations of renewable energy carriers. Oppositely, greenhouse gases emission is a severe problem in the world, which gives rise to temperature increasing year by year! Besides the global warming, some other factors also bring about uncertainties to energy supply security, so that efficient policies are necessary in order improve the recent situations and to create a secure atmosphere for energy supply, such as Directive 98/30/EC for natural gas supply security, Directive 2003/55/EC for integration and compatibility of the energy regulation and Directive 2003/54/EC, the first policy that regulates EU electricity market as well as IEM Directive, which is the improvement of Directive 2003/54/EC, etc. Although several policies aiming at creation of competitive energy markets and achieving energy supply security, vulnerabilities still exist in EU energy supply system, such as limited primary energy sources and high dependence on nuclear powers, energy network capacity inadequacy, high voltage electricity transmission, etc. Concerning Swedish energy supply system, extreme low temperatures in winter, drilling technologies and high economic budgets for heat sources from underground, hurricanes, thunderstorms to wind turbines and man-made disruptions are all potential vulnerabilities. Regarding these negative aspects, recommendations are given on four different levels, which are global, EU, Swedish and individual perspectives. Specific suggestions to achieve energy supply security include independence of different energy supplies, to enhance international cooperation, periodic assessments and inspections for energy facilities, population control, to keep original energy policies updated, to enhance abilities to resist abnormal weather conditions, to develop heat pump technologies and try to use energy in efficient ways, etc.

Purpose: There is a lack of discussion regarding end-of-life care planning which results in low advanced directive execution (AD) rates. This can lead to decision making by family, friends, and the health care team on behalf of patients whose end-of-life care wishes are unknown. The purpose of this study was to determine the effectiveness of an educational intervention in the work setting to increase end-of-life discussions and the execution of advanced directives. Methods: A descriptive design was used in an occupational workplace setting at a local bottling company after appropriate IRB approval was obtained. An educational intervention based on the Five Wishes document was presented in an occupational health setting covering all shifts and employment categories. A pre-program questionnaire measured a lack of knowledge and understanding of end-of-life planning and advanced directives. A post-program questionnaire measured the increase in knowledge and understanding of end-of-life planning and advanced directives. A focus group was conducted with audio recording to describe personal experiences. The quantitative analysis used statistical procedures to describe and synthesize data and content analysis was conducted on the focus group data. Results: A sample of 78 participants was used to gather the quantitative data. Of the total participants, an overwhelming majority were male with ethnic backgrounds evenly represented. Most of the participants either were married and either were drivers, salespeople, or warehouse workers. More participants indicated no religious affiliation than any other affiliation, and the majority of participants indicated that they had a high school diploma. When questioned about their 1) knowledge of advanced directives, 2) whether or not they would consider executing an advanced directive, 3) whether or not they were likely to discuss end-of-life care with other, 4) whether they would be comfortable having someone make end-of-life decisions on their behalf, and 5) whether or not they believed that advanced directives were important, the majority of participants indicated that they strongly agreed or agreed. However, none of the participants had executed an advanced directive. Only 10.3% of participants had ever discussed AD's with a healthcare provider. When the same participants were asked the same questions after the education portion of the study, data analysis of the pre- and post-program questionnaire mean scores, revealed a significant increase in scores on questions 1,2 and 3 (p > .05), and no significant increase on question 4 and 5 (p > .05). The implication of these findings suggest that an education intervention program in a workplace setting significantly increases end-of-life discussions and advanced directive execution rates. The Jones model of end-of-life education intervention and interpretation of the study are presented. Limitations of the study, as well as implications for nursing professionals and health care providers that will improve patient outcomes are presented. Discussion/Implication: The study shows that workplace education regarding Advanced Directives can lead to increase end-of-life discussions and increase advanced directive execution rates. Therefore, this education program at a worksite merits further research and may serve as a model program for other worksite settings.

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As a healthcare professional at the bedside, it has been very difficult to advocate for the patient while all parties involved cannot respect what the patient wants. Four out of five Americans do not have an advance directive. The history and court cases that have led the country to make patient’s right to make their own healthcare decisions has been decades in the making, yet still bring daily challenges within the healthcare system. When a patient’s wishes are not being honored, medical futility may lead to moral distress and compassion fatigue. Institutions provide multidisciplinary teams to address these issues, but if a patient’s capacity or competence is in question, their voice may not be heard. The toll on the healthcare provider and the patient can be permanently damaging, causing many nurses to leave the profession all together. I will attempt to determine the barriers to implementing the patient’s wishes, address the syndrome of moral distress among healthcare professionals, and attempt to offer solutions to promote well rounded, patient-centered care. / Urban Bioethics

Death is an inevitable part of life, yet many Americans fail to plan for this final part of life. Only about 1/3 of our country has an advance directive (Off White Papers, 2014). This underutilization of advance directives is reflected in our health care spending. It is estimated that 30% of all Medicare spending occurs during the last six months of a patient’s life. The numbers are even lower when broken down into sub-categories. Only 24% of older Black Americans possess an advance directive versus 44% of their older White counterparts (Huang, Neuhaus, & Chiong, 2016). Some studies found that African Americans were more likely to “express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs which conflict with the goals of palliative care, and distrust the healthcare system” (Johnson, Kuchibhatla, & Tulsky, 2008). Other studies have even concluded that Black race is an independent predictor of lack of advance directive possession (Huang et al., 2016). This paper further explores the possibility that race and ethnicity may simply be proxies for cultural values that impact advance directive possession. We’ll discuss the barriers, for both Black patients and health care providers, to advance directive possession as well as investigate culturally mindful interventions to combat the barriers. / Urban Bioethics

Death is inevitable, and research indicates that 80% of Americans wish to die at home. Does anyone know those wishes? Advance directives outline those wishes and personal decisions. Do advance directives make a significant difference in the experience of death for the patient, loved ones, and clinicians? Through interviews with loved ones of those who have died, as well as legal representative and a physician, this thesis examines the benefits and obstacles of having an advance directive, as well as the issues that have a high impact on whether and why an advance directive is written. Policy recommendations, business tactics, and community-based solutions are proposed to address these issues. It is clear that access to healthcare and the clinical professionals who can discuss end of life issues has a major impact on whether an advance directive is considered by the patient, along with health literacy skills and knowledge. / Urban Bioethics

Contexte : Qu’ils soient parlementaires, sociétaux ou judiciaires, les débats actuels relatifs à la fin de vie font ressortir de vives préoccupations sociales, éthiques et politiques en France et dans le monde. L’affaire « Vincent LAMBERT » illustre parfaitement les enjeux de situations médicales à la frontière de la vie et de la mort et montre ainsi les limites de l’encadrement législatif des situations de fin de vie. Les rebondissements juridictionnels successifs intervenus dans cette affaire font observer à quel point la prise de décision médicale est complexe, tiraillée entre les volontés, parfois opposées, du patient, de ses proches, voire des professionnels de santé. Objectif : L’objectif de notre recherche était d’identifier les barrières rencontrées lors de la prise de décision médicale devant mettre en œuvre un refus anticipé de traitement. Il convenait de répondre à la question suivante : un refus de soins anticipé est-il une décision impossible ? Méthodes : La première partie des travaux présentés a consisté à recueillir l’avis et évaluer les connaissances des patients et de leurs accompagnants sur les moyens qui permettent à un patient d’exprimer sa volonté par anticipation. La deuxième partie a consisté dans l’identification des critères d’efficacité et d’inefficacité des directives anticipées à travers une analyse de la littérature scientifique et une recherche en droit comparé. La troisième partie présente les difficultés rencontrées dans la mise en œuvre des décisions de limitation et d’arrêt des traitements sur les plans pratique et judiciaire. Conclusion : L’ensemble des questions soulevées au cours de cette recherche suggère la nécessité de développer, en France, des mécanismes efficients d’expression anticipée de la volonté des patients et de promouvoir leur diffusion. Les personnes désirant rédiger des directives anticipées devraient pouvoir avoir accès à un dispositif garantissant le respect et l’effectivité de leur droit à refuser un traitement. Une personne dans l’incapacité d’exprimer sa volonté devrait pouvoir exercer les mêmes droits de refuser un traitement et de voir ce choix respecté qu’une personne capable de s’exprimer. / Context: The current debates concerning the end of life deal with legal, judicial and social issues. What is clear is they all highlight some serious social, ethical and political concerns in France and in the world. The case « Vincent Lambert » shows exactly the difficulties of medical situations between the life and the death of patients, which puts in evidence the limits of the legal framework. Indeed, several judicial reversals happened in this case and illustrate well how difficult it is to make a right medical decision when the patient, their relatives and medical staff have conflicting views. Objective: The objective of our research was to identify which are the difficulties when medical staff has to make a decision applying an anticipated refusal of treatment. As a consequence, the challenge was to answer the following question: is an anticipated refusal of treatment an impossible decision? Methods: Our work was divided into three parts. The first part aimed at asking patients’ opinions as well as assessing their knowledge of the different ways to express their will in advance. Then, the second part had to determine which criteria ensure a good application of advance directives. This study was based on an analysis of the scientific literature and a work in Comparative Law. In the end, the third part presents both practical and judicial problems regarding the application of a decision whose the goal is to withhold and withdraw a life-sustaining treatment Conclusion: This research has raised several issues and it draws our attention on the need to devise effective ways to give an anticipated consent about the end of life. If people want to write advance directives, they should have the possibility to do so and make sure their right to refuse a treatment is respected. In addition, even though someone is unable to give their consent because of their condition or disease, they should be able to use the same right to refuse a treatment and should be sure their decision is respected.

Thesis (Ph. D.)--Kent State University, 2004. / Title from PDF title page (viewed on Apr. 27, 2006). Includes bibliographical references (p. 175-209).