Surrogate Decision Makers' Perspectives on Family Members' Prognosis after Intracerebral Hemorrhage.

BACKGROUND: Surrogate communication with providers about prognosis in the setting of acute critical illness can impact both patient treatment decisions and surrogate outcomes. OBJECTIVES: To examine surrogate decision maker perspectives on provider prognostic communication after intracerebral hemorrhage (ICH). DESIGN: Semistructured interviews were conducted and analyzed qualitatively for key themes. SETTING/SUBJECTS: Surrogate decision makers for individuals admitted with ICH were enrolled from five acute care hospitals. RESULTS: Fifty-two surrogates participated (mean age = 54, 60% women, 58% non-Hispanic white, 13% African American, 21% Hispanic). Patient status at interview was hospitalized (17%), in rehabilitation/nursing facility (37%), deceased (38%), hospice (4%), or home (6%). Nineteen percent of surrogates reported receiving discordant prognoses, leading to distress or frustration in eight cases (15%) and a change in decision for potentially life-saving brain surgery in three cases (6%). Surrogates were surprised or confused by providers' use of varied terminology for the diagnosis (17%) (e.g., "stroke" vs. "brain hemorrhage" or "brain bleed") and some interpreted "stroke" as having a more negative connotation. Surrogates reported that physicians expressed uncertainty in prognosis in 37%; with physician certainty in 56%. Surrogate reactions to uncertainty were mixed, with some surrogates expressing a negative emotional response (e.g., anxiety) and others reporting understanding or acceptance of uncertainty. CONCLUSIONS: Current practice of prognostic communication in acute critical illness has many gaps, leading to distress for surrogates and variability in critical treatment decisions. Further work is needed to limit surrogate distress and improve the quality of treatment decisions.

Variability in physician prognosis and recommendations after intracerebral hemorrhage.

OBJECTIVE: To assess physician prognosis and treatment recommendations for intracerebral hemorrhage (ICH) and to determine the effect of providing physicians a validated prognostic score. METHODS: A written survey with 2 ICH scenarios was completed by practicing neurologists and neurosurgeons. Selected factors were randomly varied (patient older vs middle age, Glasgow Coma Scale [GCS] score 7T vs 11, and presence vs absence of a validated prognostic score). Outcomes included predicted 30-day mortality and recommendations for initial treatment intensity (6-point scale ranging from 1 = comfort only to 6 = full treatment). RESULTS: A total of 742 physicians were included (mean age 52, 32% neurosurgeons, 17% female). Physician predictions of 30-day mortality varied widely (mean [range] for the 4 possible combinations of age and GCS were 23% [0%-80%], 35% [0%-100%], 48% [0%-100%], and 58% [5%-100%]). Treatment recommendations also varied widely, with responses encompassing the full range of response options for each case. No physician demographic or personality characteristics were associated with treatment recommendations. Providing a prognostic score changed treatment recommendations, and the effect differed across cases. When the prognostic score suggested 0% chance of functional independence (76-year-old with GCS 7T), the likelihood of treatment limitations was increased (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.12-2.33) compared to no prognostic score. Conversely, if the score suggested a 66% chance of independence (63-year-old with GCS 11), treatment limitations were less likely (OR 0.62, 95% CI 0.43-0.88). CONCLUSIONS: Physicians vary substantially in ICH prognostic estimates and treatment recommendations. This variability could have a profound effect on life and death decision-making and treatment for ICH.

Effects of Design Features of Explicit Values Clarification Methods: A Systematic Review.

BACKGROUND: Diverse values clarification methods exist. It is important to understand which, if any, of their design features help people clarify values relevant to a health decision. PURPOSE: To explore the effects of design features of explicit values clarification methods on outcomes including decisional conflict, values congruence, and decisional regret. DATA SOURCES: MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. STUDY SELECTION: Articles were included if they described the evaluation of 1 or more explicit values clarification methods. DATA EXTRACTION: We extracted details about the evaluation, whether it was conducted in the context of actual or hypothetical decisions, and the results of the evaluation. We combined these data with data from a previous review about each values clarification method's design features. DATA SYNTHESIS: We identified 20 evaluations of values clarification methods within 19 articles. Reported outcomes were heterogeneous. Few studies reported values congruence or postdecision outcomes. The most promising design feature identified was explicitly showing people the implications of their values, for example, by displaying the extent to which each of their decision options aligns with what matters to them. LIMITATIONS: Because of the heterogeneity of outcomes, we were unable to perform a meta-analysis. Results should be interpreted with caution. CONCLUSIONS: Few values clarification methods have been evaluated experimentally. More research is needed to determine effects of different design features of values clarification methods and to establish best practices in values clarification. When feasible, evaluations should assess values congruence and postdecision measures of longer-term outcomes.

Design Features of Explicit Values Clarification Methods: A Systematic Review.

BACKGROUND: Values clarification is a recommended element of patient decision aids. Many different values clarification methods exist, but there is little evidence synthesis available to guide design decisions. PURPOSE: To describe practices in the field of explicit values clarification methods according to a taxonomy of design features. DATA SOURCES: MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. STUDY SELECTION: Articles were included if they described 1 or more explicit values clarification methods. DATA EXTRACTION: We extracted data about decisions addressed; use of theories, frameworks, and guidelines; and 12 design features. DATA SYNTHESIS: We identified 110 articles describing 98 explicit values clarification methods. Most of these addressed decisions in cancer or reproductive health, and half addressed a decision between just 2 options. Most used neither theory nor guidelines to structure their design. "Pros and cons" was the most common type of values clarification method. Most methods did not allow users to add their own concerns. Few methods explicitly presented tradeoffs inherent in the decision, supported an iterative process of values exploration, or showed how different options aligned with users' values. LIMITATIONS: Study selection criteria and choice of elements for the taxonomy may have excluded values clarification methods or design features. CONCLUSIONS: Explicit values clarification methods have diverse designs but can be systematically cataloged within the structure of a taxonomy. Developers of values clarification methods should carefully consider each of the design features in this taxonomy and publish adequate descriptions of their designs. More research is needed to study the effects of different design features.

Can Text Messages Increase Empathy and Prosocial Behavior? The Development and Initial Validation of Text to Connect.

To what extent can simple mental exercises cause shifts in empathic habits? Can we use mobile technology to make people more empathic? It may depend on how empathy is measured. Scholars have identified a number of different facets and correlates of empathy. This study is among the first to take a comprehensive, multidimensional approach to empathy to determine how empathy training could affect these different facets and correlates. In doing so, we can learn more about empathy and its multifaceted nature. Participants (N = 90) were randomly assigned to receive either an empathy-building text message program (Text to Connect) or one of two control conditions (active versus passive). Respondents completed measures of dispositional empathy (i.e. self-perceptions of being an empathic person), affective empathy (i.e. motivations to help, immediate feelings of empathic concern), and prosocial behavior (i.e. self-reports and observer-reports) at baseline, and then again after the 14 day intervention period. We found that empathy-building messages increased affective indicators of empathy and prosocial behaviors, but actually decreased self-perceptions of empathy, relative to control messages. Although the brief text messaging intervention did not consistently impact empathy-related personality traits, it holds promise for the use of mobile technology for changing empathic motivations and behaviors.

Understanding ethical dilemmas in the emergency department: views from medical students' essays.

BACKGROUND: For medical students, the emergency department (ED) often presents ethical problems not encountered in other settings. In many medical schools there is little ethics training during the clinical years. The benefits of reflective essay writing in ethics and professionalism education are well established. OBJECTIVES: The purpose of this study was to determine and categorize the types of ethical dilemmas and scenarios encountered by medical students in the ED through reflective essays. METHODS: During a 4(th)-year emergency medicine rotation, all medical students wrote brief essays on an ethical situation encountered in the ED, and participated in an hour debriefing session about these essays. Qualitative analysis was performed to determine common themes from the essays. The frequency of themes was calculated. RESULTS: The research team coded 173 essays. The most common ethical themes were autonomy (41%), social justice (32.4%), nonmaleficence (31.8%), beneficence (26.6%), fidelity (12%), and respect (8.7%). Many of the essays contained multiple ethical principles that were often in conflict with each other. In one essay, a student grappled with the decision to intubate a patient despite a preexisting do-not-resuscitate order. This patient encounter was coded with autonomy, beneficence, and nonmaleficence. Common scenarios included ethical concerns when caring for critical patients, treatment of pain, homeless or alcoholic patients, access to care, resource utilization, and appropriateness of care. CONCLUSION: Medical students encounter patients with numerous ethically based issues. Frequently, they note conflicts between ethical principles. Such essays constitute an important resource for faculty, resident, and student ethics training.

What must I do to succeed?: narratives from the US premedical experience.

How does a lay person become a doctor? How is a physician made? These questions have been central to work of medical sociologists for well over a half-century. Despite this abiding focus on socialization, nearly all of the literature on this process in the US is informed by studies of the medical school and residency years, with almost no empirical attention paid to the premedical years. Our study addresses this gap in knowledge. To better understand the premedical years we conducted 49 in-depth interviews with premedical students at a selective, public Midwestern university. We found that students understand and explain decisions made during the premedical years with narratives that emphasize the qualities of achievement-orientation, perseverance, and individualism. We also find that these qualities are also emphasized in narratives employed to account for the choice to collaborate with, or compete against, premedical peers. Examination of premedical narratives, and the qualities they emphasize, enriches our understanding of how premedical education shapes a physician's moral development, and underscores the need to include the premedical years in our accounts of "becoming a doctor."

Use of the Carolina HPV Immunization Attitudes and Beliefs Scale (CHIAS) in young adult women.

BACKGROUND: Validated measures that can accurate describe young adults' HPV vaccination attitudes and how these relate to vaccination intention and receipt are needed for developing interventions to improve low HPV vaccination levels. The Carolina HPV Immunization Attitudes Scale (CHIAS) is a validated measure of these outcomes that was originally designed for parents. OBJECTIVE: To assess the performance of the CHIAS among young adult women using an exploratory factor analysis. METHODS: A convenience sample of 139 young adult women (age 18-26 years) were given the CHIAS measure at baseline. Factor analysis was used to determine attitudinal factor groupings and the association of these factors with HPV vaccination intention. A 6-month follow up assessment examined the stability of the CHIAS over time and the association of baseline vaccine factors with vaccine receipt. RESULTS: Five factors loaded on to the CHIAS in young adults - "Barriers," "Harms," "Effectiveness," "Risk Denial" and "Uncertainty," - which was similar to the factor loadings of CHIAS for parents. "Harms" was the factor most consistently associated with vaccination intention at all time points assessed. Only 5 women had received or made an appointment to receive the vaccine at the 6-month follow-up. CONCLUSIONS: In terms of categorizing HPV vaccination attitudes, the CHIAS appears to have similar performance among young adults as in parents. However, additional studies are needed to assess the utility of the CHIAS for predicting HPV vaccine receipt among the young adult population.

Animated randomness, avatars, movement, and personalization in risk graphics.

BACKGROUND: Risk communication involves conveying two inherently difficult concepts about the nature of risk: the underlying random distribution of outcomes and how a population-based proportion applies to an individual. OBJECTIVE: The objective of this study was to test whether 4 design factors in icon arrays-animated random dispersal of risk events, avatars to represent an individual, personalization (operationalized as choosing the avatar's color), and a moving avatar-might help convey randomness and how a given risk applies to an individual, thereby better aligning risk perceptions with risk estimates. METHODS: A diverse sample of 3630 adults with no previous heart disease or stroke completed an online nested factorial experiment in which they entered personal health data into a risk calculator that estimated 10-year risk of cardiovascular disease based on a robust and validated model. We randomly assigned them to view their results in 1 of 10 risk graphics that used different combinations of the 4 design factors. We measured participants' risk perceptions as our primary outcome, as well as behavioral intentions and recall of the risk estimate. We also assessed subjective numeracy, whether or not participants knew anyone who had died of cardiovascular causes, and whether or not they knew their blood pressure and cholesterol as potential moderators. RESULTS: Animated randomness was associated with better alignment between risk estimates and risk perceptions (F1,3576=6.12, P=.01); however, it also led to lower scores on healthy lifestyle intentions (F1,3572=11.1, P<.001). Using an avatar increased risk perceptions overall (F1,3576=4.61, P=.03) and most significantly increased risk perceptions among those who did not know a particular person who had experienced the grave outcomes of cardiovascular disease (F1,3576=5.88, P=.02). Using an avatar also better aligned actual risk estimates with intentions to see a doctor (F1,3556=6.38, P=.01). No design factors had main effects on recall, but animated randomness was associated with better recall for those at lower risk and worse recall for those at higher risk (F1,3544=7.06, P=.01). CONCLUSIONS: Animated randomness may help people better understand the random nature of risk. However, in the context of cardiovascular risk, such understanding may result in lower healthy lifestyle intentions. Therefore, whether or not to display randomness may depend on whether one's goal is to persuade or to inform. Avatars show promise for helping people grasp how population-based statistics map to an individual case.

Blocks, ovals, or people? Icon type affects risk perceptions and recall of pictographs.

BACKGROUND: Research has demonstrated that icon arrays (also called "pictographs") are an effective method of communicating risk statistics and appear particularly useful to less numerate and less graphically literate people. Yet research is very limited regarding whether icon type affects how people interpret and remember these graphs. METHODS: 1502 people age 35-75 from a demographically diverse online panel completed a cardiovascular risk calculator based on Framingham data using their actual age, weight, and other health data. Participants received their risk estimate in an icon array graphic that used 1 of 6 types of icons: rectangular blocks, filled ovals, smile/frown faces, an outline of a person's head and shoulders, male/female "restroom" person icons (gender matched), or actual head-and-shoulder photographs of people of varied races (gender matched). In each icon array, blue icons represented cardiovascular events and gray icons represented those who would not experience an event. We measured perceived risk magnitude, approximate recall, and opinions about the icon arrays, as well as subjective numeracy and an abbreviated measure of graphical literacy. RESULTS: Risk recall was significantly higher with more anthropomorphic icons (restroom icons, head outlines, and photos) than with other icon types, and participants rated restroom icons as most preferred. However, while restroom icons resulted in the highest correlations between perceived and actual risk among more numerate/graphically literate participants, they performed no better than other icon types among less numerate/graphically literate participants. CONCLUSIONS: Icon type influences both risk perceptions and risk recall, with restroom icons in particular resulting in improved outcomes. However, optimal icon types may depend on numeracy and/or graphical literacy skills.

Informed choice about breast cancer prevention: randomized controlled trial of an online decision aid intervention.

INTRODUCTION: Tamoxifen and raloxifene are chemopreventive drugs that can reduce women's relative risk of primary breast cancer by 50%; however, most women eligible for these drugs have chosen not to take them. The reasons for low uptake may be related to women's knowledge or attitudes towards the drugs. We aimed to examine the impact of an online breast cancer chemoprevention decision aid (DA) on informed intentions and decisions of women at high risk of breast cancer. METHODS: We conducted a randomized clinical trial, assessing the effect of a DA about breast cancer chemoprevention on informed choices about chemoprevention. Women (n = 585), 46- to 74-years old old, completed online baseline, post-test, and three-month follow-up questionnaires. Participants were randomly assigned to either an intervention group, a standard control group that answered questions about chemoprevention at baseline, or a three-month control group that did not answer questions about chemoprevention at baseline. The main outcome measures were whether women's intentions and decisions regarding chemoprevention drugs were informed, and whether women who viewed the DA were more likely to make informed decisions than women who did not view the DA, using a dichotomous composite variable 'informed choice' (yes/no) to classify informed decisions as those reflecting sufficient knowledge and concordance between a woman's decision and relevant attitudes. RESULTS: Analyses showed that more intervention than standard control participants (52.7% versus 5.9%) made informed decisions at post-test, P <0.001. At the three-month follow-up, differences in rates of informed choice between intervention (16.9%) and both control groups (11.8% and 8.0%) were statistically non-significant, P = 0.067. CONCLUSIONS: The DA increased informed decision making about breast cancer chemoprevention, although the impact on knowledge diminished over time. This study was not designed to determine how much knowledge decision makers must retain over time. Examining informed decisions increases understanding of the impact of DAs. A standard for defining and measuring sufficient knowledge for informed decisions is needed. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00967824

The undergraduate premedical experience in the United States: a critical review.

OBJECTIVES: To better understand the consequences of the premedical years for the character of (future) physicians by critically reviewing the empirical research done on the undergraduate premedical experience in the United States. METHODS: We searched ERIC, JSTOR, PubMed, Scopus, ISI Web of Science, and PsycINFO from the earliest available date for empirical, peer-reviewed studies of premedical students in the United States. We then used qualitative methods to uncover overall themes present in this literature. RESULTS: The initial literature search identified 1,168 articles, 19 of which were included for review. Reviewed articles were published between 1976 and 2010 with the majority published prior to 1990. Articles covered two broad topics: explaining attrition from the premedical track, and investigating the personality traits and stereotypes of premedical students. Self-selection bias and high attrition rates were among the limitations of the reviewed articles. CONCLUSIONS: There is very little current research on the premedical experience. Given the importance of the premedical years on the process of becoming a medical professional, it is imperative that we do more and better research on how the premedical experience shapes future physicians.

Animated graphics for comparing two risks: a cautionary tale.

BACKGROUND: The increasing use of computer-administered risk communications affords the potential to replace static risk graphics with animations that use motion cues to reinforce key risk messages. Research on the use of animated graphics, however, has yielded mixed findings, and little research exists to identify the specific animations that might improve risk knowledge and patients' decision making. OBJECTIVE: To test whether viewing animated forms of standard pictograph (icon array) risk graphics displaying risks of side effects would improve people's ability to select the treatment with the lowest risk profile, as compared with viewing static images of the same risks. METHODS: A total of 4198 members of a demographically diverse Internet panel read a scenario about two hypothetical treatments for thyroid cancer. Each treatment was described as equally effective but varied in side effects (with one option slightly better than the other). Participants were randomly assigned to receive all risk information in 1 of 10 pictograph formats in a quasi-factorial design. We compared a control condition of static grouped icons with a static scattered icon display and with 8 Flash-based animated versions that incorporated different combinations of (1) building the risk 1 icon at a time, (2) having scattered risk icons settle into a group, or (3) having scattered risk icons shuffle themselves (either automatically or by user control). We assessed participants' ability to choose the better treatment (choice accuracy), their gist knowledge of side effects (knowledge accuracy), and their graph evaluation ratings, controlling for subjective numeracy and need for cognition. RESULTS: When compared against static grouped-icon arrays, no animations significantly improved any outcomes, and most showed significant performance degradations. However, participants who received animations of grouped icons in which at-risk icons appeared 1 at a time performed as well on all outcomes as the static grouped-icon control group. Displays with scattered icons (static or animated) performed particularly poorly unless they included the settle animation that allowed users to view event icons grouped. CONCLUSIONS: Many combinations of animation, especially those with scattered icons that shuffle randomly, appear to inhibit knowledge accuracy in this context. Static pictographs that group risk icons, however, perform very well on measures of knowledge and choice accuracy. These findings parallel recent evidence in other data communication contexts that less can be more-that is, that simpler, more focused information presentation can result in improved understanding. Decision aid designers and health educators should proceed with caution when considering the use of animated risk graphics to compare two risks, given that evidence-based, static risk graphics appear optimal.

Motives for volunteering are associated with mortality risk in older adults.

OBJECTIVE: The purpose of this study is to examine the effects of motives for volunteering on respondents' mortality risk 4 years later. METHODS: Logistic regression analysis was used to examine whether motives for volunteering predicted later mortality risk, above and beyond volunteering itself, in older adults from the Wisconsin Longitudinal Study. Covariates included age, gender, socioeconomic variables, physical, mental, and cognitive health, health risk behaviors, personality traits, received social support, and actual volunteering behavior. RESULTS: Replicating prior work, respondents who volunteered were at lower risk for mortality 4 years later, especially those who volunteered more regularly and frequently. However, volunteering behavior was not always beneficially related to mortality risk: Those who volunteered for self-oriented reasons had a mortality risk similar to nonvolunteers. Those who volunteered for other-oriented reasons had a decreased mortality risk, even in adjusted models. CONCLUSIONS: This study adds to the existing literature on the powerful effects of social interactions on health and is the first study to our knowledge to examine the effect of motives on volunteers' subsequent mortality. Volunteers live longer than nonvolunteers, but this is only true if they volunteer for other-oriented reasons.

Association between nonverbal communication during clinical interactions and outcomes: a systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis of studies reporting associations between patients' and clinicians' nonverbal communication during real clinical interactions and clinically relevant outcomes. METHODS: We searched 10 electronic databases, reference lists, and expert contacts for English-language studies examining associations between nonverbal communication measured through direct observation and either clinician or patient outcomes in adults. Data were systematically extracted and random effects meta-analyses were performed. RESULTS: 26 observational studies met inclusion criteria. Meta-analysis was performed for patient satisfaction, which was assessed in 65% of studies. Mental and physical health status were evaluated in 23% and 19% of included studies, respectively. Both clinician warmth and clinician listening were associated with greater patient satisfaction (p<0.001 both). Physician negativity was not related to patient satisfaction (p=0.505), but greater nurse negativity was associated with less patient satisfaction (p<0.001). Substantial differences in study design and nonverbal measures existed across studies. CONCLUSION: Greater clinician warmth, less nurse negativity, and greater clinician listening were associated with greater patient satisfaction. Additional studies are needed to evaluate the impact of nonverbal communication on patients' mental and physical health. PRACTICE IMPLICATIONS: Communication-based interventions that target clinician warmth and listening and nurse negativity may lead to greater patient satisfaction.

On holiday: a risk behavior profile for men who have vacationed at gay resorts.

Sexual risk behavior is higher when people vacation as compared to when they are at home. The current study uses survey data to compare sexual risk behavior of gay men who vacation at gay resorts to those who do not. Independent predictors of vacationing at gay resorts included income level, relationship status, ever having attended a circuit party, and HIV serostatus. For men who visit resorts to meet sex partners, independent predictors included relationship status, ever having attended a circuit party, HIV serostatus, number of male sex partners in the past six months, and number of anal insertive male partners using a condom. These results show a need for the development of structural interventions in the gay resort and hotel setting.