Would you be surprised if this patient died?: Preliminary exploration of first and second year residents' approach to care decisions in critically ill patients

BACKGROUND: How physicians approach decision-making when caring for critically ill patients is poorly understood. This study aims to explore how residents think about prognosis and approach care decisions when caring for seriously ill, hospitalized patients. METHODS: Qualitative study where we conducted structured discussions with first and second year internal medicine residents (n = 8) caring for critically ill patients during Medical Intensive Care Unit Ethics and Discharge Planning Rounds. Residents were asked to respond to questions beginning with "Would you be surprised if this patient died?" RESULTS: An equal number of residents responded that they would (n = 4) or would not (n = 4) be surprised if their patient died. Reasons for being surprised included the rapid onset of an acute illness, reversible disease, improving clinical course and the patient's prior survival under similar circumstances. Residents reported no surprise with worsening clinical course. Based on the realization that their patient might die, residents cited potential changes in management that included clarifying treatment goals, improving communication with families, spending more time with patients and ordering fewer laboratory tests. Perceived or implied barriers to changes in management included limited time, competing clinical priorities, "not knowing" a patient, limited knowledge and experience, presence of diagnostic or prognostic uncertainty and unclear treatment goals. CONCLUSIONS: These junior-level residents appear to rely on clinical course, among other factors, when assessing prognosis and the possibility for death in severely ill patients. Further investigation is needed to understand how these factors impact decision-making and whether perceived barriers to changes in patient management influence approaches to care

Default risk, state ownership and the cross-section of stock returns: evidence from China

We apply a structural model to estimate firm-level default risk in China and investigate the stock return predictability of default risk and the moderating effects of state ownership for the sample period from 2003 to 2015. We show unique evidence that in China, default risk is positively associated with expected stock returns and state ownership matters considerably to the return predictability of default risk. We find investors of state-owned enterprises (SOEs) are not compensated appropriately in China despite of their higher default risk exposure. Our empirical evidence supports the conjecture on shareholder advantages and suggests that a strong bargaining power of equity holders would have a negative impact on stock returns

Earn-Outs in debt restructuring plans: economics and valuation

Outstanding academic literature mainly deals with Earn-Outs in M&As. Scarce attention has been paid to Earn-Out provisions in debt-restructuring plans. The topic is, however, of particular relevance within the more general issue of troubled debt restructuring and option pricing methodlogies. In general terms, Earn-Outs are tied to the company’s performance. They are often struc-tured as long-term long or short options (often, European call options) where the under-lying is related to certain financial margins, ratios or cash flows (revenues, EBITDA, operational cash flows, free cash flow, Return on Investments, Return on Assets). This paper first aims at providing insight to the rationale of Earn-Out provisions for fi-nancially distressed firms that agree upon some debt restructuring plans with creditors. Moreover, the work investigates the basic principles of Earn-Outs’ economic valuation. After discussing the main implications of Earn-Out value estimation at light of extant literature on corporate restructuring and option pricing related issues, we propose a valu-ation methodology based on a Monte Carlo simulation approach which allows to repre-sent a multitude of paths of a few relevant financial variables along with the related prob-ability distribution. Besides coming to an assessment of the economic values, our model allows for a probabilistic representation (not necessarily under a risk-neutral environ-ment) of the wide spectrum of the restructured debt pay-offs, for both the company and the bank