Health Care and Nursing Education and Guidelines for Risk and End of Life Decision

What Is Concept of Risk

    Especially when the balance of potential harms and benefits from
treatment options is close, patient understanding of numerical expressions of
risk is central to health decision making. Yet, many current practices in
expressing and communicating risk are not research based. For example, in the
field of genetic counseling risk has traditionally been expressed in
proportions (1 in 112) rather than in rates (8.9 per 1,000). 

    In two studies,
understood rates were significantly better than they did proportions (Grimes
& Snively, 1999; van Vliet, Grimes, Popkin, & Smith, 2001). Women with
little formal education had difficulty understanding risks framed either way.

Guidelines for  Risk In Health Care  and Nursing

    The European Community guideline descriptions of risk very common,
common, uncommon, rare, and very rare-led to significant overestimation of the
likelihood of adverse effects (Berry, Raynor, Knapp, & Bersellini, 2003).
And although drugs are exhaustively tested before marketing, the wording in the
information sheets that accompany them is not tested at all.

    Visual communication of risk is often helpful. Line graphs are
excellent for conveying trends, and pie charts help in depicting proportions.
Figure 3.1 depicts a visual means of communicating risk. Another helpful
approach is to use a common denominator. If risk is expressed as 1 in 25 or 1
in 200, individuals frequently think 1 in 200 is a bigger risk, presumably
because the denominator is larger (Paling. 2003). Clearly, much work remains to
be done in developing means of expressing risk reliably understandable by
various populations. 

End of Life Decisions Making I Health Care and Nursing 

    Two ways in which educational interventions can be of help in
making end-of-life decisions include encouraging a higher completion rate of
advance directives (ADs) and information in managing end-of-life care. Written
materials alone fail to ensure completion of ADs. 

    Supplemented with educational
interventions by health care providers, individualized information and
counseling sessions, and use of videos and case scenarios result in higher
completion rates. 

    Using such interventions, the Let Me Decide AD program showed
a 49% completion rate among competent residents and a 78% completion rate among
families of incompetent residents. Intervention in nursing homes resulted in
fewer hospitalizations per resident and less resource use. As ever, this
program did require investment in a full time staff member for 6-8 months
(Molloy et al., 2000).

    At end of life, the balance between encouraging use of advanced
supportive technology when it is of benefit, but limiting its burdens when it
is ineffective, is frequently difficult to achieve. 

    Because it is difficult for
patients and families to accept that technology has become ineffective or will
not result in a functional outcome that is acceptable to the patient, access to
palliative care is often delayed for dying critically ill patients, and they
continue to consume a disproportionate amount amount of intensive care
resources. 

    One trial (Lilly et al., 2000) educated patients and family about
appropriate clinical milestones and held formal family meetings after the
provider team had reached consensus that restoration of function or survival
were unlikely. Failure to meet these milestones allowed patient and family to
know that advanced supportive technology had been ineffective and that it was
time to explore alternatives including palliative care. 

    Intensive communication
in this intervention accomplished greater concordance among patients, families,
and providers and resulted in fewer preterminal days of intensive care for
dying patients. Because this trial was neither randomized nor double blinded,
additional evidence must be sought.