Browsing by Subject "medical decision making"

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    D-Dimer and Exhaled CO2/O2 to Detect Segmental Pulmonary Embolism in Moderate-Risk Patients
    (2010-09) Kline, Jeffrey A.; Hogg, Melanie M; Courtney, D Mark; Miller, Chadwick D; Jones, Alan E; Smithline, Howard A; Klekowski, Nicole; Lanier, Randy
    Rationale: Pulmonary embolism (PE) decreases the exhaled end-tidal ratio of carbon dioxide to oxygen (etCO2/O2). Objectives: To test if the etCO2/O2 can produce clinically important changes in the probability of segmental or larger PE on computerized tomography multidetector-row pulmonary angiography (MDCTPA) in a moderate-risk population with a positive D-dimer. Methods: Emergency department and hospitalized patients with one or more predefined symptoms or signs, one or more risk factors for PE, and 64-slice MDCTPA enrolled from four hospitals. D-dimer greater than 499 ng/ml was test(+), and D-dimer less than 500 ng/ml was test(−). The median etCO2/O2 less than 0.28 from seven or more breaths was test(+) and etCO2/O2 greater than 0.45 was test(−). MDCTPA images were read by two independent radiologists and the criterion standard was the interpretation of acute PE by either reader. PE size was then graded. Measurements and Main Results: We enrolled 495 patients, including 60 (12%) with segmental or larger, and 29 (6%) with subsegmental PE. A total of 367 (74%) patients were D-dimer(+), including all 60 with segmental or larger PE (posterior probability 16%). The combination of D-dimer(+) and etCO2/O2(+) increased the posterior probability of segmental or larger PE to 28% (95% confidence interval [CI] for difference of 12%, 3.0–22%). The combination of D-dimer(+) and etCO2/O2(−) was observed in 40 patients (8%; 95% CI, 6–11%), and none (0/40; 95% CI, 0–9%) had segmental or larger PE on MDCTPA. No strategy changed the prevalence of subsegmental PE. Conclusions: In moderate-risk patients with a positive D-dimer, the et etCO2/O2 less than 0.28 significantly increases the probability of segmental or larger PE and the etCO2/O2 greater than 0.45 predicts the absence of segmental or larger PE on MDCTPA.
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    Doctor, What Would You Do?: An ANSWER for patients requesting advice about value-laden decisions
    (AAP, 2015-10) Edmonds, Brownsyne Tucker; Torke, Alexia M.; Helft, Paul; Wocial, Lucia D.; Department of Obstetrics and Gynecology, IU School of Medicine
    This article presents a previously published framework, summarized in the mnemonic ANSWER (A, Active listening; N, Needs assessment; S, Self-awareness/reflection; W, Whose perspective?; E, Elicit values; R, Respond) for how to respond to the question, “Doctor, what would you do?” when considering medical decisions that are preference-sensitive, meaning there is limited or debatable evidence to guide clinical recommendations, or are value-laden, such that the “right” decision may differ based on the context or values of a given individual. Using the mnemonic and practical examples, we attempt to make the framework for an ethically appropriate approach to these conversations more accessible for clinicians. Rather than a decision rule, this mnemonic represents a set of points to consider when physicians are considering an ethically acceptable response that fosters trust and rapport. We apply this approach to a case of periviable counseling, among the more emotionally challenging and value-laden antenatal decisions faced by providers and patients.