Items in AFP with MESH term: Decision Making
ABSTRACT: Ethnic minorities currently compose approximately one third of the population of the United States. The U.S. model of health care, which values autonomy in medical decision making, is not easily applied to members of some racial or ethnic groups. Cultural factors strongly influence patients' reactions to serious illness and decisions about end-of-life care. Research has identified three basic dimensions in end-of-life treatment that vary culturally: communication of "bad news"; locus of decision making; and attitudes toward advance directives and end-of-life care. In contrast to the emphasis on "truth telling" in the United States, it is not uncommon for health care professionals outside the United States to conceal serious diagnoses from patients, because disclosure of serious illness may be viewed as disrespectful, impolite, or even harmful to the patient. Similarly, with regard to decision making, the U.S. emphasis on patient autonomy may contrast with preferences for more family-based, physician-based, or shared physician- and family-based decision making among some cultures. Finally, survey data suggest lower rates of advance directive completion among patients of specific ethnic backgrounds, which may reflect distrust of the U.S. health care system, current health care disparities, cultural perspectives on death and suffering, and family dynamics. By paying attention to the patient's values, spirituality, and relationship dynamics, the family physician can elicit and follow cultural preferences.
ABSTRACT: Each year, pacemaker therapy is prescribed to approximately 900,000 persons worldwide. Current pacemaker devices treat bradyarrhythmias and tachyarrhythmias and, in some cases, are combined with implantable defibrillators. In older patients, devices that maintain synchrony between atria and ventricles are preferred because they maintain the increased contribution of atrial contraction to ventricular filling necessary in this age group. In general, rate-responsive devices are preferred because they more closely simulate the physiologic function of the sinus node. Permanent pacemakers are implanted in adults primarily for the treatment of sinus node dysfunction, acquired atrioventricular block, and certain fascicular blocks. They also are effective in the prevention and treatment of certain tachyarrhythmias and forms of neurocardiogenic syncope. Biventricular pacing (resynchronization therapy) recently has been shown to be an effective treatment for advanced heart failure in patients with major intraventricular conduction effects, predominately left bundle branch block. Many studies have documented that pacemaker therapy can reduce symptoms, improve quality of life and, in certain patient populations, improve survival.
ABSTRACT: Controversy surrounds the management options for localized prostate cancer-conservative management, prostatectomy, and radiation. Choosing among these options is difficult because of long-term side effects that include sexual, urinary, and bowel dysfunction. Some recent studies suggest that patients who have chosen treatment (i.e., radical prostatectomy or radiation) have longer disease-free survival compared with patients who have chosen conservative management (i.e., watchful waiting). However, several biases may artificially enhance the perceived value of treatment and make the interpretation of studies on treatment outcomes difficult. Sources of bias include lead time, length time, and patient selection. Because of the uncertain efficacy of management options and the risk of long-term treatment complications, family physicians need to engage their patients in the decision-making process.
Treatment of Lateral Epicondylitis - Article
ABSTRACT: Lateral epicondylitis is a common overuse syndrome of the extensor tendons of the forearm. It is sometimes called tennis elbow, although it can occur with many activities. The condition affects men and women equally and is more common in persons 40 years or older. Despite the prevalence of lateral epicondylitis and the numerous treatment strategies available, relatively few high-quality clinical trials support many of these treatment options; watchful waiting is a reasonable option. Topical nonsteroidal anti-inflammatory drugs, corticosteroid injections, ultrasonography, and iontophoresis with nonsteroidal anti-inflammatory drugs appear to provide short-term benefits. Use of an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) may improve function during daily activities. Progressive resistance exercises may confer modest intermediate-term results. Evidence is mixed on oral nonsteroidal antiinflammatory drugs, mobilization, and acupuncture. Patients with refractory symptoms may benefit from surgical intervention. Extracorporeal shock wave therapy, laser treatment, and electromagnetic field therapy do not appear to be effective.
ABSTRACT: Prostate cancer is the second most common cancer in men, with a lifetime prevalence of 17 percent. Prostate cancer symptoms generally occur in advanced stages, making early detection desirable. Digital rectal examination and prostate-specific antigen testing are the most commonly used screening tools. The goal of screening is to detect clinically significant prostate cancers at a stage when intervention reduces morbidity and mortality; however, the merits and methods of screening continue to be debated. Prostate-specific antigen levels may be less than 4 ng per mL in 15 to 38 percent of men with cancer, indicating a high false-negative rate. The positive predictive value of the prostate-specific antigen test is approximately 30 percent; therefore, less than one in three men with an abnormal finding will have cancer on biopsy. These limitations of the prostate-specific antigen test have led to variations designed to improve its accuracy (e.g., age- and race-specific cutoffs, free prostate-specific antigen tests); however, none of these modifications have been widely adopted because of unclear benefits. Although treatments have improved in the past two decades, therapy for prostate cancer is not benign and may lead to urinary incontinence, sexual dysfunction, or bowel dysfunction. New evidence affecting screening recommendations continues to accumulate, and two large randomized controlled trials of screening will be completed in the next few years. Current guidelines recommend an individualized, targeted, patient-centered discussion to facilitate a shared decision about screening plans.
Cancer Screening in the Older Patient - Article
ABSTRACT: Although there are clear guidelines that advise at what age to begin screening for various cancers, there is less guidance concerning when it may be appropriate to stop screening. The decision to stop screening must take into account patients' age; overall health and life expectancy; the natural history of the disease; and the risks, expense, and convenience of the screening test, and any subsequent testing and treatment. The U.S. Preventive Services Task Force and the American Academy of Family Physicians suggest that Papanicolaou smears can be discontinued in women at 65 years of age, provided they have had adequate recent normal screenings. Evidence suggests that cessation of breast cancer screening at approximately 75 to 80 years of age is appropriate, although American Geriatric Society guidelines recommend cessation at a more advanced age. Studies support continuing colon cancer screening until approximately 75 years of age in men and 80 years of age in women for patients without significant comorbidities. Prostate cancer screening, if conducted at all, may be discontinued at approximately 75 years of age in otherwise healthy men. Ultimately, the decision to screen or to discontinue screening must be made after careful discussion with each patient, using evidence-based guidelines and individual patient preferences.
Prostate Cancer Screening: Let Patients Decide - Editorials
ABSTRACT: To take the best possible care of patients, physicians must understand the basic principles of diagnostic test interpretation. Pretest probability is an important factor in interpreting test results. Some tests are useful for ruling in disease when positive or ruling out disease when negative, but not necessarily both. Many tests are of little value for diagnosing disease, and tests should be ordered only when the results are likely to lead to improved patient-oriented outcomes.
What My Brother Knew - Close-ups
Making Sense of Health Plan Denials - Feature