Mapping French Laypeople's Views Regarding Living Organ Donation.

BACKGROUND: French laypeople's views on living organ donation (LOD) were examined. METHODS: From 2010 to 2014, 327 adults (including 21 nurses) judged the acceptability of LOD in 60 realistic scenarios composed of all combinations of 5 factors: 1. type of organ; 2. whether it could have been obtained from a cadaver; 3. donor-recipient relationship; 4. donor's level of autonomy; 5. financial compensation; and 6. patients' level of responsibility for their illness. In all scenarios, the patients were in need of a kidney or liver transplantation. The ratings were subjected to cluster analysis and analyses of variance. RESULTS: Five qualitatively different positions were found that were termed Free Market (22%), Pragmatism (15%), Altruism (48%), Always Acceptable (7%), and Undetermined (8%). Nurses comprised the majority (90%) of the members of the altruism cluster. Younger and more-educated people were, more frequently than older and less-educated people, members either of the pragmatism or of the free market cluster. CONCLUSIONS: Half of French adults support the altruism model of LOD. A substantial minority, however, mostly young and more educated people, support alternative models allowing the introduction of financial incentives.

Telling children their mother is seriously ill or dying: mapping French people's views.

BACKGROUND: What to tell children when their mother's life is seriously endangered is a largely unstudied issue. METHODS: We had 255 lay persons in France judge the appropriateness of the parents' behaviour in 48 scenarios of parents dealing with this problem. The scenarios comprised according to a four within-subject orthogonal design: child's age (4, 6, 8 or 10 years), severity of disease (lethal or worrisome but curable), child's concern or not about his or her mother's illness and parents' decision about how much to tell (tell nothing, minimize or tell the full truth). RESULTS: Cluster analysis revealed four clusters, labelled 'always tell the truth' (33%), 'tell the truth or minimize' (16%), 'tell nothing or minimize' (22%) and 'depends on child's age and level of concern' (29%). Women and participants who had already faced breaking bad news like this to children were more frequently members of the two 'tell the truth' clusters than other participants. CONCLUSIONS: People who have already experienced a situation of having to tell a child about their mother's bad health tend to think, more than others, that telling the truth is the best policy.

Lay people's and health professionals' views about breaking bad news to children.

BACKGROUND: Bad health news is difficult to communicate, especially when parents must give bad news to their children. METHODS: We had 170 lay persons, 33 nurses and six physicians in Toulouse, France, judge the appropriateness of the parents' behaviour in 64 scenarios of parents dealing with this problem. The scenarios were composed according to a four within-subject orthogonal design: child's age (4, 6, 8 or 10), severity of disease (lethal or worrisome but curable), child's concern or not about his illness and parents' decision about communicating the news (tell nothing, minimize, tell the truth or ask the physician to tell the truth). RESULTS: Cluster analysis revealed four clusters, labelled 'Always Tell the Truth' (33%, including a majority of doctors and nurses), 'Tell Nothing or Minimize' (16%, with an older average age), 'Tell the Truth Except in Cases of Incurable Illness' (22%) and 'Depends on Child's Characteristics' (29%). CONCLUSIONS: Physicians in training and in practice need to be aware that lay people--and likely parents as well--have diverse and complex opinions about when and how parents should give bad health news to their children.

Emotional-motivational barriers to blood donation among Togolese adults: a structural approach.

BACKGROUND: Although the number of blood donors has been rapidly increasing in Togo since 2003, it is nevertheless insufficient to cover the demand. OBJECTIVES: To increase needed blood donation in Togo, it is necessary to understand why most people are reluctant to do it. METHODS: A sample of 400 adult volunteers in Lomé, mostly university educated, rated, on a scale of 0-10, the relevance to them of a comprehensive list of reasons that might deter people from donating blood. The ratings of 250 participants were subjected to factor analysis, and the resulting factorial structure was confirmed on the ratings of the other 150 participants. RESULTS: The resulting six factors were labelled (in order of their ratings of a representative sample of items): Lack of Courage and Lack of Information (mean 5·43 of 10), Concerns about the Use of Blood (4·72), Risk Aversion (4·37), Fear of Medical Settings (2·41), Conformity with Tradition (1·88) and Indifference to Others and Hostility to the Procedure (1·69). CONCLUSION: To increase blood donation, a public information campaign should address the emotional-motivational barriers found even in the most educated segment of Togolese society.

The acceptability among French lay persons of ending the lives of damaged newborns.

BACKGROUND: Lay persons' judgements of the acceptability of the not uncommon practice of ending the life of a damaged neonate have not been studied. METHODS: A convenience sample of 1635 lay people in France rated how acceptable it would be for a physician to end a neonate's life-by withholding care, withdrawing care, or active euthanasia-in 54 scenarios in which the neonate was diagnosed either with perinatal asphyxia or a genetic abnormality. The scenarios were all combinations of four factors: three levels of maturity or immaturity, three levels of severity of the health problem, three levels of parents' preference concerning prolonging care and two levels of decision-making (with or without consulting the other caregivers). ANALYSES: Analyses of variance of the participants' responses were performed to determine the importance of each factor; the interactions among factors, with methods of ending life and with other patient characteristics; and the differences between asphyxia and genetic abnormality. A cluster analysis was performed to look for groups with different patterns of responses. RESULTS: Lay people assigned most importance to the parents' request and to the severity of the problem. Except for a small group (12%) always opposed to ending life, they used a simple additive-type rule in integrating the information. IMPLICATIONS: Most of this sample of French lay people are not categorically for or against ending the life of a damaged neonate, but judge its degree of acceptability by adding up those factors that seem most salient to them.

Knowledge of the risks associated with skin bleaching among Togolese users.

We examined the extent of Togolese users' knowledge of the health risks associated with the regular use of bleaching agents. A massive underestimation of some of the main risks was discovered. The more frequent the use of bleaching agents, the higher the underestimation.

Do French lay people and health professionals find it acceptable to breach confidentiality to protect a patient's wife from a sexually transmitted disease?

OBJECTIVE: To determine under what conditions lay people and health professionals find it acceptable for a physician to breach confidentiality to protect the wife of a patient with a sexually transmitted disease (STD). METHODS: In a study in France, breaching confidentiality in 48 scenarios were accepted by 144 lay people, 10 psychologists and 7 physicians. The scenarios were all possible combinations of five factors: severity of the disease (severe, lethal); time taken to discuss this with (little time, much time); intent to inform the spouse about the disease (none, one of these days, immediately); intent to adopt protective behaviours (no intent, intent); and decision to consult an expert in STDs (yes, no), 2 x 2 x 3 x 2 x 2. The importance and interactions of each factor were determined, at the group level, by performing analyses of variance and constructing graphs. RESULTS: The concept of breaching confidentiality to protect a wife from her husband's STD was favoured much more by lay people and psychologists than by physicians (mean ratings 11.76, 9.28 and 2.90, respectively, on a scale of 0-22). The patient's stated intentions to protect his wife and to inform her of the disease had the greatest impact on acceptability. A cluster analysis showed groups of lay participants who found breaching confidentiality "always acceptable" (n = 14), "depending on the many circumstances" (n = 87), requiring "consultation with an expert" (n = 30) and "never acceptable (n = 13)". CONCLUSIONS: Most people in France are influenced by situational factors when deciding if a physician should breach confidentiality to protect the spouse of a patient infected with STD.

The acceptability of ending a patient's life.

OBJECTIVES: To clarify how lay people and health professionals judge the acceptability of ending the life of a terminally ill patient. DESIGN: Participants judged this acceptability in a set of 16 scenarios that combined four factors: the identity of the actor (patient or physician), the patient's statement or not of a desire to have his life ended, the nature of the action as relatively active (injecting a toxin) or passive (disconnecting life support), and the type of suffering (intractable physical pain, complete dependence, or severe psychiatric illness). PARTICIPANTS: 115 lay people and 72 health professionals (22 nurse's aides, 44 nurses, six physicians) in Toulouse, France. MAIN MEASUREMENTS: Mean acceptability ratings for each scenario for each group. RESULTS: Life ending interventions are more acceptable to lay people than to the health professionals. For both, acceptability is highest for intractable physical suffering; is higher when patients end their own lives than when physicians do so; and, when physicians are the actors, is higher when patients have expressed a desire to die (voluntary euthanasia) than when they have not (involuntary euthanasia). In contrast, when patients perform the action, acceptability for the lay people and nurse's aides does not depend on whether the patient has expressed a desire to die, while for the nurses and physicians unassisted suicide is more acceptable than physician assisted suicide. CONCLUSIONS: Lay participants judge the acceptability of life ending actions in largely the same way as do healthcare professionals.

When is physician assisted suicide or euthanasia acceptable?

OBJECTIVES: To discover what factors affect lay people's judgments of the acceptability of physician assisted suicide and euthanasia and how these factors interact. DESIGN: Participants rated the acceptability of either physician assisted suicide or euthanasia for 72 patient vignettes with a five factor design--that is, all combinations of patient's age (three levels); curability of illness (two levels); degree of suffering (two levels); patient's mental status (two levels), and extent of patient's requests for the procedure (three levels). PARTICIPANTS: Convenience sample of 66 young adults, 62 middle aged adults, and 66 older adults living in western France. MAIN MEASUREMENTS: In accordance with the functional theory of cognition of N H Anderson, main effects, and interactions among patient factors and participants' characteristics were investigated by means of both graphs and ANOVA. RESULTS: Patient requests were the most potent determinant of acceptability. Euthanasia was generally less acceptable than physician assisted suicide, but this difference disappeared when requests were repetitive. As their own age increased, participants placed more weight on patient age as a criterion of acceptability. CONCLUSIONS: People's judgments concur with legislation to require a repetition of patients' requests for a life ending act. Younger people, who frequently are decision makers for elderly relatives, place less emphasis on patient's age itself than do older people.

Do gender and race affect decisions about pain management?

OBJECTIVE: To determine if patient gender and race affect decisions about pain management. DESIGN, SETTING, AND PARTICIPANTS: Experimental design using medical vignettes to evaluate treatment decisions. A convenience sample of 111 primary care physicians (61 men, 50 women) in the Northeast was asked to treat 3 hypothetical patients with pain (kidney stone, back pain) or a control condition (sinusitis). Symptom presentation and severity were held constant, but patient gender and race were varied. MEASUREMENTS AND MAIN RESULTS: The maximum permitted doses of narcotic analgesics (hydrocodone) prescribed at initial and return visits were calculated by multiplying mg per pill x number of pills per day x number of days x number of refills. No overall differences with respect to patient gender or race were found in decisions to treat or in the maximum permitted doses. However, for renal colic, male physicians prescribed higher doses of hydrocodone to white patients versus black patients (426 mg vs 238 mg), while female physicians prescribed higher doses to blacks (335 mg vs 161 mg, F1,85 = 9.65, P =.003). This pattern was repeated for persistent kidney stone pain. For persistent back pain, male physicians prescribed higher doses of hydrocodone to males than to females (406 mg vs 201 mg), but female physicians prescribed higher doses to females (327 mg v. 163 mg, F1,28 = 5.50, P =.03). CONCLUSION: When treating pain, gender and racial differences were evident only when the role of physician gender was examined, suggesting that male and female physicians may react differently to gender and/or racial cues.

Eliciting patient disutilities for the adverse outcomes of cardiopulmonary resuscitation.

BACKGROUND: in helping patients decide about treatments, such as whether to authorize cardiopulmonary resuscitation (CPR), physicians typically present information about the possible outcomes and their likelihoods. The aim of this study was to elicit patient disutilities for the adverse outcomes of cardiopulmonary resuscitation (CPR) using the methodology of NH Anderson's functional theory of cognition and to determine how patients integrate the disutility and the likelihood of an outcome. METHODS: 77 French adults rated scenarios of possible outcomes of CPR on a linear scale with anchors "what would be the best (or worst) for me." In 25 of the 27 scenarios, the result would be either total recovery or one of five adverse outcomes (chest injury, mild reversible brain damage, severe irreversible brain damage, death after intensive care, immediate death) with one of five likelihoods (one to five chances out of ten). In the other two, the only possible result was either total recovery or immediate death. RESULTS: the mean disutilities relative to 0 for chest injury and 100 for severe brain damage were 13 for mild brain injury, 68 for death after intensive care, and 69 for immediate death. The graphs of the ratings of each adverse outcome in relation to its frequency were fan-shaped, showing that participants integrated this information multiplicatively. CONCLUSIONS: the functional theory of cognition provides an alternate method of eliciting patient utilities for the outcomes of CPR and supports clinicians' assumption that people combine utility and likelihood multiplicatively.

Self-assessment of inebriation from external indices.

OBJECTIVE: The objective was to study people's judgments, through the use of external indices, of their expected degree of inebriation and to characterize the cognitive processes involved in making these judgments. METHOD: The participants were 143 adults living in France. In accordance with N. H. Anderson's functional theory of cognition (1982, 1996), their primary task was to read 64 cards depicting drinking situations characterized by three parameters: number of glasses, type of drink, and temporal relation to eating; to associate with each situation a certain degree of personal intoxication; and to indicate this degree of expected intoxication on linear scale anchored by Not at all drunk and Extremely drunk. RESULTS: Participants were able to judge the general direction and combination of effects. They indicated incorrectly, however, that incremental effects decrease at higher levels of consumption (4 or more glasses) and at higher concentrations of alcohol in a drink. On the other hand, they indicated correctly that eating food decreases the impact of drinking alcohol. Drinkers and nondrinkers used different rules for self-assessment from external indices. IMPICATIONS: The systematic errors in both drinkers' and nondrinkers' use of external clues could, unless corrected, result in their becoming more inebriated than intended.

Relationship between cigarette dose and perceived risk of lung cancer.

BACKGROUND: Most people are aware that smoking cigarettes increases the risk of ill health, in particular of lung cancer. The precise way in which they relate amount of exposure to smoke and level of health risk has not, however, been determined. METHODS: A convenience sample of 155 French adolescents and adults ages 15 to 75 rated the risk of "smoker's cancer"--the popular term for lung cancer--in 24 scenarios depicting eight levels of daily cigarette consumption of three concentrations of nicotine. The data were analyzed according to functional measurement methodology to ascertain the forms of the relationship between exposure and perceived risk. RESULTS: All subjects perceived that the risk of smoker's cancer increased as smoking increased. Yet at high levels of consumption, additional cigarettes were generally judged to result in decreasing increments of risk, regardless of the nicotine content of the cigarettes and the sex and smoking status of the participants. Adolescents, however, were more likely than adults to perceive a linear, rather than a negatively accelerated, relationship. CONCLUSIONS: The actual form of the relationship between the dose of cigarette smoke and risk of lung cancer is either linear or positively accelerated. Public health educators and physicians should be aware that, at least in France, many people, particularly adults, incorrectly perceive this relationship as negatively accelerated.

Measuring patient preferences by willingness to pay to avoid: the case of acute otitis media.

The aim of this study was to evaluate willingness to pay (WTP) to avoid as a method of eliciting relative values for use in expected-value (EV) decision making. Parents' preferences for the events and outcomes associated with acute otitis media (AOM) and its treatment were quantified by means of a questionnaire asking how much they would be willing to pay to avoid them. Their responses were then used to calculate the EVs of treating or not treating presumed AOM with antibiotics. The advantages of the WTP method were its simplicity, its analogy with everyday financial transactions, its explicit recognition of illness and its management as involving decreases in value, and its face validity. The disadvantages included the need to use another method (the standard gamble) to derive a value for death and the wide ranges and the poor test-retest reliability of individual parents' responses. Nonetheless, median WTP values and their ranges may prove useful in defining for physicians and policymakers the parameters of their practical management decisions. In the case of AOM, the EV of treating with antibiotics was, for the aggregate sample and for most individual parents, robustly superior because of parents' desire to avoid any increased risk of their children's death.

Striking against managed care: the last gasp of la médicine libérale?

The French health care system combines a strong tradition of autonomous private practice with nearly universal health care coverage through the social security system. The French state's responses to rising health care expenditures have included limitation of the number of medical students, control over physician fees, rules to prohibit certain clinical practices, experiments with generalist physicians coordinating care and access to specialists, and collective physician responsibility for expenditures beyond the health care budget. The failure of physicians' protests, including a strike of French residents and fellows in 1997, may signify the end of traditional private practice in the face of France's statist version of managed care.

Physicians' diagnostic judgments and treatment decisions for acute otitis media in children.

Physicians' diagnoses of acute otitis media (AOM) and their treatment choices were investigated using judgment and decision-making analyses. Thirty-two pediatricians in the Albany, New York, area provided probability judgments of the presence of AOM and made treatment decisions for 32 patient vignettes, each described in terms of historical and examination variables. Their probability judgments were well predicted by linear combinations of the patient variables (R2s ranged from 0.76 to 0.97). Information about the observed condition of the eardrum proved to be most critical to the physicians' diagnoses. They demonstrated good levels of agreement on diagnoses. They varied, however, in their tendencies to treat with amoxicillin rather than another antibiotic. Case vagueness was related to the rate of antibiotic treatment. The rate of antibiotic treatment was higher for vague than for non-vague cases when the mean judged probability of AOM was low. In combination, the findings highlight the importance of performing and interpreting ear examinations and the role that consistent training may have in improving management of AOM.

Physicians' opinions on compensation for telephone calls.

OBJECTIVES: To describe the attitudes of pediatricians and other physicians practicing in a fee-for-service environment toward compensation for telephone encounters with patients. DESIGN: Survey by mail. PARTICIPANTS: The 67 pediatric and 634 other private physicians and medical school faculty of Albany County, NY. RESULTS: A total of 479 of all the physicians (68.3%) and 55 of the pediatricians (82.1%) returned the questionnaire. Of these, 69.9% of the total (95% confidence interval, 65.5% to 74.1%) and 58.2% of the pediatricians (95% confidence interval, 44.1% to 71.3%) indicated physicians should be compensated for calls with patients, especially for after-hours calls. This opinion was significantly associated with greater concern about liability for calls, more negative sentiments about after-hours calls, and a longer reported duration of calls. After adjusting for these factors, surgeons and pediatricians were significantly less likely to favor compensation than the group as a whole. Pediatricians in favor of compensation suggested charging a mean of $9.18 (SD $5.05) for 1 to 5 min, $14.00 (SD $8.87) for 6 to 10 min, and $22.27 (SD $12.62) for >10 min. Pediatricians reported documenting in patients' charts a mean of 35. 3% (SD 39.9%) of after-hours calls. CONCLUSIONS: In a mostly noncapitated environment, the majority of pediatricians and other physicians favor compensation for telephone calls with patients. Some specialists, in particular pediatricians and surgeons, are, however, less likely to support this. Additional research into the reasons for these interspecialty differences may help to guide policy decisions on the financing of health care.