This code of practice for health professionals was prepared by a multi-professional group and reflects good clinical practice in encouraging dialogue about individuals' wishes concerning their future treatment. It has a broad practical approach, considers a range of advance statements, advises of dangers and benefits of making treatment decisions in advance and combines annotated code of practice with a quick pull out guide for easy reference.

Like the authors of some of the other responses to Schneiderman, Jecker, and Jonsen, I too was one of the group that produced “An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Futile and Potentially Inappropriate Treatments in Intensive Care Units”. Furthermore, ethical and legal issues surrounding futile and potentially inappropriate medical treatment have been a primary focus of my scholarship for more than a decade. Schneiderman, Jecker, and Jonsen offer a strong critique of the Multiorganization Statement, (...) but they do not describe it with sufficient precision. There are points of true normative disagreement between the... (shrink)

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, how (...) decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

This article presents an analysis of contractual relations in sport from the standpoint of the Croatian legislative system. Due to the complexity of the subject matter, the author considers only a small fragment of it - the significance and the role of sport in Croatian society and the law of contracts „as a cornerstone on which „sports law“ has been built and which is of primary importance in most areas where there is an interface between sport and the law, (...) irrespective of whether the sport is being played at an elite level or at a more humble one“. Bearing in mind the limited extent of this article, the autor tries to provide some clarifications and some guidance on how to deal with the designation and the determination of the applicable law for contracts in the sporting context. Considering that there are different legal regimes which may come into play with regard to the designation of the law applicable to contracts in the sporting context, the author first presents the determination of the applicable law according to the Rome I Regulation and then according to the Croatian Arbitration Act, Swiss Private International Law Act and the CAS Code of Sports-related Arbitration, as the most common in sports practice. Then, the author deals with contracts concluded with minor athletes and the determination of the law applicable to some preliminary questions. Finally, the author presents her perception of the problems encountered and some suggestions for the improvement of the existing legal framework. (shrink)

This article discusses what level of consent is needed from a child or parent before a primary-school medical can take place . It also considers whether there are occasions when a doctor can see a child if the parents have failed to give consent or have explicitly refused consent.Primary-school children are considered incompetent to make decisions about their own medical treatment and so their consent does not need to be gained before a medical takes (...) place, although it is highly desirable to obtain it. However, a doctor cannot justify a decision to see a child purely in terms of the benefit conferred on the child. Parents can be wronged if their wishes are ignored and usually those wishes should be considered overriding. Normally, general consent, which need not be fully informed, is needed before a school medical. However, if a child is considered to be in danger of being harmed significantly or suspected to have a major medical condition, a medical should go ahead regardless of the level of consent obtained from the parent, so that a reasonable standard of health is maintained for the child. (shrink)

BackgroundThe Life Extension Medical Decision law enacted on February 4, 2018 in South Korea was the first to consider the suspension of futile life-sustaining treatment, and its enactment caused a big controversy in Korean society. However, no study has evaluated whether the actual implementation of life-sustaining treatment has decreased after the enforcement of this law. This study aimed to compare the provision of patient consent before and after the enforcement of this law among cancer patients who visited (...) a tertiary university hospital's emergency room to understand the effects of this law on the clinical care of cancer patients.MethodsThis retrospective single cohort study included advanced cancer patients aged over 19 years who visited the emergency room of a tertiary university hospital. The two study periods were as follows: from February 2017 to January 2018 (before) and from May 2018 to April 2019 (after). The primary outcome was the length of hospital stay. The consent rates to perform cardiopulmonary resuscitation (CPR), intubation, continuous renal replacement therapy (CRRT), and intensive care unit (ICU) admission were the secondary outcomes.ResultsThe length of hospital stay decreased after the law was enforced from 4 to 2 days (p = 0.001). The rates of direct transfers to secondary hospitals and nursing hospitals increased from 8.2 to 21.2% (p = 0.001) and from 1.0 to 9.7%, respectively (p < 0.001). The consent rate for admission to the ICU decreased from 6.7 to 2.3% (p = 0.032). For CPR and CRRT, the consent rates decreased from 1.0 to 0.0% and from 13.9 to 8.8%, respectively, but the differences were not significant (p = 0.226 and p = 0.109, respectively).ConclusionAfter the enforcement of the Life Extension Medical Decision law, the length of stay in the tertiary university hospital decreased in patients who established their life-sustaining treatment plans in the emergency room. Moreover, the rate of consent for ICU admission decreased. (shrink)

Objectives: The objectives of the study were to assess similarities and differences between breast cancer patients and their husbands in terms of doctor-patient/spouse relationships and shared decision making; and to investigate the association between breast cancer patients and husbands in terms of preference of type of doctor, doctor-patient relationship, and shared decision making regarding medical treatment. Method: Fifty-seven women with breast cancer, and their husbands, completed questionnaires measuring doctor-patient/spouse relationships, and decision making regarding medical treatment. Results: (...) Patients believe they have a key role in the medical decision-making process and that the participation of their husbands, and their agreement with the decision, is important. Both breast cancer patients and their husbands prefer a shared decision-making process to paternalistic or autonomy-based approaches. Conclusion: In contrast to legal and bioethical approaches, which focus on the patient as the primary decision maker, this study reflects a practical recognition of the role of the breast cancer patient's husband in the decision-making process. It also reflects a relational rather than an individualistic perception of patient autonomy. (shrink)

Douglas T. Going above and beneath the call ….

Background: By providing healthcare to adolescents, a major opportunity is created to help them cope with the challenges in their lives, develop healthy behaviour and become responsible healthcare consumers. Confidentiality is a major issue in adolescent healthcare, and its perceived absence may be the main barrier to an adolescent seeking medical care. Little is known, however, about confidentiality for adolescents in primary care practices in Spain.Objective: To ascertain the attitudes of Spanish family doctors towards the right of adolescents (...) to confidentiality in different healthcare situations and in the prescription of treatment.Method: A descriptive postal questionnaire was self-administered by family doctors.Results: Parents of patients under 18 years are always informed by 18.5% of family doctors, whereas parents of those under 16 years are informed by 38.8% of doctors. The patients are warned of this likelihood by 79.3% of doctors. The proportion of doctors supporting confidentiality for adolescents increases with the age and maturity of the patients, whereas workload and previous training has a negative effect.Conclusions: Spanish laws on adolescent healthcare are not reflected by the paternalistic attitude that Spanish primary care doctors have towards their adolescent patients. Doctors need to be provided with up-to-date and clinically relevant explanations on contemporary legal positions. In primary care, more attention should be paid to adolescents’ rights to information, privacy and confidentiality. Doctors should be more aware of the need to encourage communication between teenagers and their parents, while also safeguarding their patients’ rights to confidential care. (shrink)

Is it ever right to prescribe placebos to patients in clinical practice? The General Medical Council is ambivalent about the issue; the American Medical Association asserts that placebos can be administered only if the patient is (somehow) ‘informed’. The potential problem with placebos is that they may involve deception: indeed, if this is the case, an ethical tension arises over the patient's autonomy and the physician's requirement to be open and honest, and the notion that medical care (...) should be the primary concern. This paper examines the case of depression as an entry point for understanding the complexities of the prescription of placebos. Recent important meta-analyses of antidepressants claim that they are not significantly more effective in a clinical setting than placebos. Given that antidepressants have numerous adverse side effects and are hugely expensive, this provocative research has serious potential ethical and practical implications for patients and medical providers. Should placebos be prescribed in place of antidepressants? The case of depression highlights another important issue which medical ethical codes have hitherto overlooked: well-being is not synonymous with being realistic about oneself, one's circumstances and the future. While severely depressed individuals are unduly pessimistic about themselves and the world around them, treatment of depressed individuals can be deemed successful when patients have successfully attained those positive illusions that are indicative of psychological health. This is exactly what successful psychological treatments of depression seem to achieve. It is therefore possible that there may be a limited unavoidable role for deception in medicine. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Obesity Treatment:One Size Does Not Fit AllKarin KwambaiI am obese. That phrase is actually very hard for me to say out loud. Saying it feels as if I am standing at an “obesity anonymous” meeting, except there is nothing anonymous about being fat. Everyone knows it. I often feel that it is the first and only thing people notice about me. I’ve been overweight, chubby, fat my entire (...) life. My mom enrolled me in Weight Watchers when I was 12 years old; I learned to use Molly McButter in front of her and sneak oatmeal cream pies when she wasn’t looking. I’ve learned a lot of maladjusted behaviors around food over a lifetime of trying to lose weight. I’ve tried meal replacement shakes, pills, souping, juicing, and the “Master Cleanse”—a diet of lemonade with cayenne pepper and maple syrup. All of these tactics only messed up my mind and body even more. The summer before my freshman year of college, I literally ate only an apple a day because I was so worried about not making new friends because of my weight. It was not about being healthy; it was about being accepted.Twenty years of blame and shame later, and despite mixed reviews on its success, Weight Watchers is still the first recommendation for weight loss from my doctor, along with Medifast, a 1000 calorie a day diet, or bariatric surgery. My naturopath told me to make my smoothies and spinach salads smaller, and my therapist told me I think too much about exercise and should “just do it.” I have gone many rounds with Weight Watchers and had some success. I have also had success losing weight by tracking food intake and exercise on apps like My Fitness Pal. But like all attempts at losing weight, following medical advice works until it stops working, and the weight comes back—plus some.Obesity as a DiseaseI recently sought treatment with an Obesity Specialist, but after an inspiring complimentary consult where she explained her holistic approach, I found out that my health insurance won’t cover the cost because the diagnostic code for obesity is excluded from my coverage. I have heard that the Affordable Care Act is supposed to impact insurance plans covering the cost of obesity treatment, but that has not been the case for me. In fact, I’ve been forced to pay out of pocket several times for labs that doctors feel the need to run, despite my urging that I am not diabetic. Trust me, I say; I know what diabetes looks like. I have watched family die and seen clients suffer, and I am earning my Masters in Public Health. I had been hopeful that the recent classification of obesity as a disease by the American Medical Association would open treatment doors, but it has not. In fact, I’m concerned that it will close doors for treatment opportunities because of how insurance [End Page 104] companies decide what medical costs they will cover. Obesity seems to be a four–letter word for health insurance companies. My insurance plan will cover prescription medications for high blood pressure, high blood sugar, and high cholesterol, but it won’t cover weight loss medications. Where is the incentive to address weight loss before potentially developing a life–threatening disease? I believe that obesity is a disease; I just don’t trust how the healthcare system will handle the responsibility of addressing it as such.In fact, the debate on whether obesity is a disease or a lifestyle is a frustrating one for me. If we claim lifestyle is the cause of obesity, it means that there is only one factor causing obesity. If that were true, then the commonly prescribed solution of “eat less, move more” would be more effective. The reality is, there is no single cause or cure for obesity; there is no one–size–fits–all treatment approach. It is a complex problem that deserves a complex response in the forms of primary, secondary and tertiary public health interventions. I am hopeful that classifying obesity as a disease will lead to more disease model research... (shrink)

Objectives: To describe the concerns and priorities of key stakeholders in a developing country regarding ethical obligations held by researchers and perceptions of equity or “what is fair” for study participants in an HIV/AIDS clinical drug trial. Design: Qualitative study with focus groups. Setting: Teaching and referral hospital and rural health centre in western Kenya. Participants: Potential HIV/AIDS clinical trial participants, clinician researchers, and administrators. Results: Eighty nine individuals participated in a total of 11 focus groups over a four month (...) period. The desire for continued drug therapy, most often life long, following an HIV/AIDS clinical trial was the most common priority expressed in all focus groups. Patients with and without HIV/AIDS also thought subsidisation of drug therapies and education were critical forms of compensation for clinical trial participation. Financial incentives were considered important primarily for purchasing drug therapy as well as obtaining food. Patients noted a concern for the potential mismanagement of any money offered. Clinician researchers and administrators felt strongly that researchers have a moral obligation to participants following a trial to provide continued drug therapy, adverse event monitoring, and primary care. Finally, clinician researchers and administrators stressed the need for thorough informed consent to avoid coercion of study participants. Conclusions: Kenyan patients, clinician researchers, and administrators believe that it would be unfair to stop antiretroviral therapy following an HIV/AIDS clinical trial and that researchers have a long term obligation to participants. (shrink)

Background Medical research so flawed as to be retracted may put patients at risk by influencing treatments. Objective To explore hypotheses that more patients are put at risk if a retracted paper appears in a journal with a high impact factor (IF) so that the paper is widely read; is written by a ‘repeat offender’ author who has produced other retracted research; or is a clinical trial. Methods English language papers (n=788) retracted from the PubMed database between 2000 and (...) 2010 were evaluated. Only those papers retracting research with humans or freshly derived human material were included; 180 retracted primary papers (22.8%) met inclusion criteria. Subjects enrolled and patients treated were tallied, both in the retracted primary studies and in 851 secondary studies that cited a retracted primary paper. Results Retracted papers published in high-IF journals were cited more often (p=0.0004) than those in low-IF journals, but there was no difference between high- and low-IF papers in subjects enrolled or patients treated. Retracted papers published by ‘repeat offender’ authors did not enrol more subjects or treat more patients than papers by one-time offenders, nor was there a difference in number of citations. However, retracted clinical trials treated more patients (p=0.0002) and inspired secondary studies that put more patients at risk (p=0.0019) than did other kinds of medical research. Conclusions If the goal is to minimise risk to patients, the appropriate focus is on clinical trials. Clinical trials form the foundation of evidence-based medicine; hence, the integrity of clinical trials must be protected. (shrink)

Over 50% of the world population will develop a psychiatric disorder in their lifetime. 1 In the realm of psychiatric treatment, two primary modalities have been established: pharmacotherapy and psychotherapy. Yet, pharmacological interventions often take precedence as the initial treatment choice despite their comparable outcomes, severe side effects and disputed evidence of their efficacy. This preference for medication foregrounds a vital re-examination of what it means to be invasive in medical treatments, namely in psychiatric care. De (...) Marco _et al_ challenge the standard account of invasiveness, presenting considerations that transcend the traditional criteria of physical intrusion. 2 Through case studies centred on treatments for schizophrenia and depression, we aim to (1) reinforce De Marco _et al_’s challenge to the standard account of invasiveness and (2) extend the dialogue to the moral imperative of redefining mental invasiveness. Our aims are to broaden the definition of mental invasiveness, aligning... (shrink)

Delay in seeking medical services is common in elderly populations, which leads to disease progression and life difficulty. This study aims to assess the prevalence of delay in medical visits and treatment and define associated effects and factors in patients with senile cataract, which may help obtain a better understanding of late-life psychopathology and provide the basis for interventions. Patients aged more than 60 years were prospectively recruited in Zhongshan Ophthalmic Center. All participants were diagnosed with binocular (...) senile cataract and decided to have primary surgery in ZOC. The distributions of the popularity of delaying outpatient visits and treatment, the degrees of visual impairment, the influences on quality of life, and the reasons for delaying treatment among participants were accessed by the descriptive statistics. Factors associated with the perceptions of cataract treatment were accessed using a binary logistic regression model. A total of 400 senile patients aged from 60 to 94 years were enrolled. At diagnosis, 82 participants had a low vision with monocular acuity of both eyes below 0.05. All participants have felt that their normal lives were affected, and 64 participants felt that their lives were affected severely. Only 17 participants have sought for medical services immediately after feeling vision loss, and 294 participants have felt vision loss since a year ago before seeking medical help. A total of 298 participants have delayed the surgery time, and 229 patients delayed it for more than 12 months. There were 147 participants delaying surgery on account of no knowledge about it and 114 participants delaying surgery because of fear. There are a high proportion of elderly patients with senile cataract delaying their outpatient visits and surgery treatment, whose normal lives were severely affected. Increasing medical service propaganda about cataract and other common diseases in elderly populations would probably be helpful for improving perceptions of diseases and decreasing medical delays. Public needs to draw more attention to the healthy and medical status of the elderly ocular patients. (shrink)

El presente texto se inscribe dentro de la temática dirigida a la investigación sobre la violencia intrafamiliar. Tiene como objetivo sistematizar aspectos históricos y teóricos inherentes al estudio del maltrato infantil y sus consecuencias en el ámbito social y familiar para su detección y tratamiento en el nivel de atención primaria de los servicios de salud en Cuba. Mediante una revisión bibliográfica se logró concretar un análisis documental de materiales y textos en soporte digital e impreso que condujo a los (...) acercamientos teórico e histórico del fenómeno en el ámbito internacional y nacional, para su conceptualización, la determinación de su tipología y el establecimiento de sus consecuencias; elementos imprescindibles del saber profesional del futuro egresado de las ciencias médicas, en función de su desempeño en los diferentes niveles de atención de salud, en especial, la atención primaria. The text falls within the research on intrafamiliar violence subject matter. Its objective is to systematize historical and theoretical aspects inherent to the study of child abuse and its consequences within the social and domestic scopes for its detection and treatment in the Cuban primary health care services. By means of a bibliographic review, a documentary analysis of electronic and printed form materials and texts was summarized. It led to theoretical and historical approaches to the phenomenon within the national and international scopes for its conceptualization, the establishment of its typology and consequences. They are essential elements of the professional knowledge of future medical sciences graduates towards their performance in different health care levels, especially in primary health care. (shrink)

This book is a resource for providers and students, integrating germane basic science information with clinical-medicine insights. The goal is to improve primary-care outpatient interactions for physicians, APRNs, and PAs. It is unique, integrating germane basic-science information with clinical-medicine. Unlike other resources that introduce these concepts more distinctly, this book bridges the gap and provides insights for providers and students. Also, there are succinct, yet comprehensive, presentations on managing the more common out-patient problems. The book is designed for (...) class='Hi'>primary care providers and students, e.g., physicians, APRNs, and PAs, who desire to improve their patient-education, diagnostic, and treatment skills. The PEARLS are instruments to embellish and emphasize important concepts. The focus of the book is to improve outpatient medicine delivery, and better informed and confident providers are keys to the process. (shrink)

Modern medicine has produced many successful theories concerning the causes of diseases. For example, we know that tuberculosis is caused by the bacterium Mycobacterium tuberculosis, and that scurvy is caused by a deficiency of vitamin C. This chapter discusses the nature of medical theories from the perspective of the philosophy, history, and psychology of science. I will review prominent philosophical accounts of what constitutes a scientific theory, and develop a new account of medical theories as representations of mechanisms (...) that explain disease. An account of the nature of medical theories should illuminate many aspects of the development and application of medical knowledge. Most importantly, it should contribute to understanding of medical explanation, both at the general level of causes of diseases and at the individual level of diagnosis of particular cases of a disease. Medical researchers seek to explain the causes of diseases such as tuberculosis, while physicians seek to identify diseases that explain symptoms such as fever. A medical theory such as the bacterial theory of tuberculosis provides good explanations at both the general and individual levels. The primary aim of this chapter is to show how these explanations work. A secondary aim is to show how an account of medical theories can shed light on other aspects of medical research and practice, including the nature of medical discovery, the process of evaluation of competing medical theories, and the ways in which effective treatments of disease depend on the development of good mechanistic theories about diseases. (shrink)

Since the 1970s, estrogen have sometimes been used in adolescent girls to reduce very tall adult expected height. Worries about long-term effects have led to a proposal to link treatment data with cancer registers. How should one deal with informed consent for such a study? We designed a qualitative study with semi-structured telephone interviews. From 1200 women who were to be followed-up in cancer registers, we randomly selected 22 women. Major themes were a wish to be involved and a (...) positive attitude to the proposed register research. The women did not express worry after reading the study protocol, but did convey considerable frustration that this research had not been initiated earlier. Active consent was not seen as crucial. We found strong interest in a high participation rate and a concern over missing data. The selection of information and consent or the decision to go ahead without consent in register follow-up is a delicate balancing act. Study participants wish to be contacted, but acknowledge the primary goal of answering important questions. Our study provides support for safeguarding privacy in epidemiological linkage studies and in follow-up of medical treatment without losing the scientific value by requesting for informed consent. (shrink)

Since the 1970s, estrogen have sometimes been used in adolescent girls to reduce very tall adult expected height. Worries about long-term effects have led to a proposal to link treatment data with cancer registers. How should one deal with informed consent for such a study? We designed a qualitative study with semi-structured telephone interviews. From 1200 women who were to be followed-up in cancer registers, we randomly selected 22 women. Major themes were a wish to be involved and a (...) positive attitude to the proposed register research. The women did not express worry after reading the study protocol, but did convey considerable frustration that this research had not been initiated earlier. Active consent was not seen as crucial. We found strong interest in a high participation rate and a concern over missing data. The selection of information and consent or the decision to go ahead without consent in register follow-up is a delicate balancing act. Study participants wish to be contacted, but acknowledge the primary goal of answering important questions. Our study provides support for safeguarding privacy in epidemiological linkage studies and in follow-up of medical treatment without losing the scientific value by requesting for informed consent. (shrink)

BackgroundExpanded access is the use of investigational drugs (IDs) outside of clinical trials. Generally it is performed in patients with serious and life-threatening diseases who cannot be treated satisfactorily with authorized drugs. Legal regulations of expanded access to IDs have been introduced among others in the USA, the European Union (EU), Canada and Australia. In addition, in the USA an alternative to expanded access is treatment under the Right-to-Try law. However, the treatment use of IDs is inherently associated (...) with a number of ethically relevant problems.Main textThe objective of this article is to present a coherent framework made up of eight requirements which have to be met for any treatment use of an ID to be ethical. These include a justified need for the use of an ID, no threat to clinical development of the ID, adequate scientific evidence to support the treatment, patient’s benefit as the primary goal of the use of an ID, informed decision of a patient, fair access of patients to IDs, independent review, as well as the dissemination of treatment results.ConclusionsWhile this framework is essentially consistent with the legal regulations of expanded access of the USA, the EU, Canada and Australia, it is substantially wider in scope because it addresses some important issues that are not covered by the regulations. Overall, the framework that we developed minimizes the risks and threats, and maximizes potential benefits to each of the four key stakeholders involved in the treatment use of IDs including patients, doctors, drug manufacturers, and society at large. (shrink)

Background: The experimental method to acquire knowledge about efficacy and efficiency of medical procedures is well established in evidence-based medicine. A method to attain evidence about the significance of diseases and interventions from the patients' perspectives taking into account their right to self-determination about their lives and bodies has however not been sufficiently characterized.Design: Identification of a method to acquire evidence about the clinical significance of disease and therapeutic options from the patients' perspectives.Arguments: Communication between patient and physician is (...) analyzed as the method to attain evidence about what is at stake for individual patients in disease and therapy. It is the method that enables physicians to directly take into account patients' disease experiences and their aims regarding treatments. These patients' perspectives in turn determine the clinical significance of diagnoses and therapeutic options, if patient-autonomy is taken seriously.Conclusions: A full account of evidence-based medicine needs to include experimentation and communication between physician and patient as equally important methods to attain evidence necessary to practice patient-oriented medicine. The communicative method is especially important for primary physicians as they direct patients within the medical system to have their medical problems most effectively and efficiently addressed. (shrink)

The COVID-19 pandemic has highlighted the difficult task of balancing access to misinformation with respect for patient decision-making. Due to its innate antagonism, the paradigm of “physician paternalism” versus “patient autonomy” may not adequately capture the clinical relationship. The authors hypothesized that most patients would, in fact, prefer significant physician input as opposed to unopinionated information when making medical decisions. There is a lack of empirical data corroborating this in the United States. To that end, a survey was distributed (...) to 650 individuals through Amazon Mechanical Turk, of which 499 responses met pre-determined quality criteria. Most respondents believed their doctor's insight would be better than their own if injured or gravely ill. When asked to affirm preferences separately, a significantly higher proportion of respondents preferred guidance from their doctor when making medical decisions compared to being presented with unopinionated information ( p < 0.001). Encouragingly, 93.1% believed that the doctor's primary goal was their health. When asked directly to compare physician guidance to unopinionated information, 69.1% respondents stated they would prefer physician guidance. We found a consistent association between educational/economic background and affirmative responses ( p < 0.001), suggesting particular attention should be paid to patients that are disadvantaged with respect to these demographic factors. The belief in a shared goal, and a consistent preference for physician input, suggests that patients endorse a more collaborative view of the clinical dynamic than is suggested by the paternalism-autonomy paradigm. This pilot study suggests physicians should not be afraid to communicate conviction with regard to treatment decisions. (shrink)

Background: The bioethics literature contains speculation but little data about sociodemographic differences between patients for whom ethics committees (EC) are consulted for conflict about life-sustaining treatment (LST) and the broader hospital population that these committees serve. To provide an empirical context for this discussion, we examined differences in five sociodemographic factors between patients for whom an EC was consulted for conflict over LST and the general inpatient population, hypothesizing that nonwhite patients were most likely to be disproportionately represented. Methods: (...) This was a retrospective cohort study comparing self-reported race/ethnicity, household income, insurance status, primary language, and religious affiliation between patients involved in EC consultations for conflict over LST and the general adult inpatient population at a large academic hospital from January 1, 2007, through December 31, 2013. Results: There were 169 EC consultations involving conflict over LST and 243,197 adult inpatient admissions over the study period. On bivariate analysis, patients for whom the EC was consulted for conflict over LST were more likely to be nonwhite, low-income, and to speak a primary language other than English. They were not more likely to be underinsured or to report a religious affiliation. On multivariate analysis, patients for whom the EC was consulted for conflict over LST were more likely to be nonwhite (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.7–3.7; p <.001). They were also more likely to be low income (OR, 1.8; 95% CI, 1.1–3.0; p =.02). They were not more likely to speak a primary language other than English (OR, 1.4; 95% CI, 0.9–2.1; p =.17). None of the assessed variables were associated with conflict over LST requiring additional meetings beyond the first EC consultation. Conclusions: Nonwhite and low-income status patients are disproportionately represented in EC committee consultation for conflict over LST compared to the general inpatient population. (shrink)

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primary care providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacological care and are differentially vulnerable to deleterious outcomes associated with misdiagnosis (...) and overmedication. Taken together, these factors fuel inequities in the access, quality, and utilization of mental health care. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitable care across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy. (shrink)

BackgroundNew metrics have been developed to assess the impact of research and provide an indication of online media attention and data dissemination. We aimed to describe online media attention of articles evaluating cancer treatments and identify the factors associated with high online media attention.MethodsWe systematically searched MEDLINE via PubMed on March 1, 2015 for articles published during the first 6 months of 2014 in oncology and medical journals with a diverse range of impact factors, from 3.9 to 54.4, and (...) selected a sample of articles evaluating a cancer treatment regardless of study design. Altmetric Explorer was used to identify online media attention of selected articles. The primary outcome was media attention an article received online as measured by Altmetric score (i.e., number of mentions in online news outlets, science blogs and social media). Regression analysis was performed to investigate the factors associated with high media attention, and regression coefficients represent the logarithm of ratio of mean (RoM) values of Altmetric score per unit change in the covariate.ResultsAmong 792 articles, 218 (27.5%) received no online media attention (Altmetric score = 0). The median [Q1–Q3] Altmetric score was 2.0 [0.0–8.0], range 0.0–428.0. On multivariate analysis, factors associated with high Altmetric score were presence of a press release (RoM = 10.14, 95%CI [4.91–20.96]), open access to the article (RoM = 1.48, 95%CI [1.02–2.16]), and journal impact factor (RoM = 1.10, 95%CI [1.07–1.12]. As compared with observational studies, systematic reviews were not associated with high Altmetric score (RoM = 1.46, 95%CI [0.74–2.86]; P = 0.27), nor were RCTs (RoM = 0.65, 95%CI [0.41–1.02]; P = 0.059) and phase I/ii non-RCTs (RoM = 0.58, 95%CI [0.33–1.05]; P = 0.07). The articles with abstract conclusions favouring study treatments were not associated with high Altmetric score (RoM = 0.97, 95%CI [0.60–1.58]; P = 0.91).ConclusionsMost important factors associated with high online media attention were the presence of a press release and the journal impact factor. There was no evidence that study design with high level of evidence and type of abstract conclusion were associated with high online media attention. (shrink)

Background/IntroductionInfertile couples that travel to another country for reproductive treatment do not refer to themselves as “reproductive tourists”. They might even be offended by this term. “Tourism” is a metaphor with hidden connotations. We will analyze these connotations in public media discourses on “reproductive tourism” in Israel and Germany. We chose to focus on these two countries since legal, ethical and religious restrictions give couples a similar motivation to travel for reproductive care, while the cultural backgrounds and conceptions of (...) reproduction are different. Results: Our research shows that the use of the metaphor “reproductive treatment” and its hidden messages depends on the writers’ intention and the target population. Although the phenomenon of patients travelling for reproductive treatment can fit into the definitions of tourism, the term emphasizes aspects that do not reflect patients’ reality. In both the German and the Israeli public media debate the term “reproductive tourism” is either used to criticize the economic aspects of the phenomenon or to attract patients as potential clients. Conclusions: Ethicists should be cautious when borrowing metaphors like “reproductive tourism” from the public debate. Our findings support Penning’s suggestion to use instead an unloaded term like cross-border reproductive care to describe the phenomenon in a more neutral way and to make it explicit whenever criticism is necessary. (shrink)

Evidence based medicine has had an increasing impact on primary care over the last few years. In the UK it has influenced the development of guidelines and quality standards for clinical practice and the allocation of resources for drug treatments and other interventions. It has informed the thinking around patient involvement in decision making with the concept of evidence based patient choice. There are, however, concerns among primary care clinicians that evidence based medicine is not always relevant to (...) primary care and that undue emphasis placed on it can lead to conflict with a clinician’s duty of care and respect for patient autonomy. In this paper we consider the impact of evidence based medicine on primary care, and the ethical implications of its increasing prominence for clinicians and managers in primary care. (shrink)

Since 1980, the number of twin births in the United States has increased 76 percent, and the number of triplets or higher‐order multiples has increased over 400 percent. These increases are due in part to increased maternal age, which is associated with spontaneous twinning. But the primary reason for these increases is that more and more people are undergoing fertility treatment. Despite an emerging (but not absolute) consensus in the medical literature that multiples, including twins, should be (...) a far less frequent outcome of fertility treatment, American clinicians currently practice fertility medicine in ways likely to result in twins and, occasionally, triplets—often, they tell us, at the request of their patients. At first blush, one might conclude that these practice patterns show that patients and their doctors have weighed the risks associated with twins against the benefits of swiftly completing their families and decided that the risks are worth taking. That is, their requests for twins must represent their free and informed choices. But there are reasons to be skeptical of this interpretation, including that the preferences of many patients seem to be very strongly shaped, if not sometimes completely constrained, by concerns about costs—costs that mainly result from the routine exclusion of in vitro fertilization from health insurance coverage. It is quite possible, we believe, that these cost concerns actually undermine the autonomy of fertility patients, pushing many of them to take risks with their health and the health of their hoped‐for future children. (shrink)

Objectives—To investigate the factors considered by staff, and the practicalities involved in the decision making process regarding the withdrawal or withholding of potential life-sustaining treatment in a children's hospital. To compare our current practice with that recommended by the Royal College of Paediatrics and Child Health guidelines, published in 1997.Design—A prospective, observational study using self-reported questionnaires.Setting—Tertiary paediatric hospital.Patients and participants—Consecutive patients identified during a six-month period, about whom a formal discussion took place between medical staff, nursing staff and (...) family regarding the withholding or withdrawal of potentially life-sustaining treatments. The primary physician and primary nurse involved in the discussion were identified.Method—Two questionnaires completed independently by the primary physician and nurse.Results—Twenty-two patients were identified . In 20 cases treatment was withdrawn or withheld, in two cases treatment was continued. Nursing staff considered family wishes and family perceptions of patient suffering as significantly more important factors in decision making than medical staff, who considered prognostic factors as most important. In only two cases were the patient's expressed wishes apparently available. In most cases staff considered the patient's best interests were served and the process would not be enhanced by the involvement of an independent ethics committee. The exceptions were those cases in which treatment was continued following disagreement between parties.Conclusions—Our current practice is consistent with that recommended by the RCPCH. The contribution of the patient, provision of staff counselling and general practitioner involvement were identified as areas for improvement. (shrink)

Since 1980, the number of twin births in the United States has increased 76 percent, and the number of triplets or higher-order multiples has increased over 400 percent. These increases are due in part to increased maternal age, which is associated with spontaneous twinning. But the primary reason for these increases is that more and more people are undergoing fertility treatment. Despite an emerging (but not absolute) consensus in the medical literature that multiples, including twins, should be (...) a far less frequent outcome of fertility treatment, American clinicians currently practice fertility medicine in ways likely to result in twins and, occasionally, triplets-often, they tell us, at the request of their patients. At first blush, one might conclude that these practice patterns show that patients and their doctors have weighed the risks associated with twins against the benefits of swiftly completing their families and decided that the risks are worth taking. That is, their requests for twins must represent their free and informed choices. But there are reasons to be skeptical of this interpretation, including that the preferences of many patients seem to be very strongly shaped, if not sometimes completely constrained, by concerns about costs-costs that mainly result from the routine exclusion of in vitro fertilization from health insurance coverage. It is quite possible, we believe, that these cost concerns actually undermine the autonomy of fertility patients, pushing many of them to take risks with their health and the health of their hoped-for future children. [ABSTRACT FROM AUTHOR]. (shrink)

IntroductionThere is a paucity of clinical guidelines for the routine assessment of maladaptive reproductive grief reactions in outpatient primary care and OB-GYN settings in the United States. Because of the disenfranchised nature of perinatal grief reactions, many clinicians may be apt to miss or dismiss a grief reaction that was not identified in the perinatal period. A significant number of those experiencing a reproductive loss exhibit signs of anxiety, depression, or post-traumatic stress disorder. Reproductive losses are typically screened for (...) and recorded numerically as part of a woman’s well-visit intake, yet this process often fails to identify patients emotionally troubled by a prior pregnancy loss.Materials and MethodsA summative content analysis of 164 recent website blogs from female participants who self-reported having experienced a miscarriage or abortion in their lifetime was conducted. The narratives were reviewed for details regarding the time span between the pregnancy loss and the composition of the blog post. The stories were analyzed for subsequent relationship problems and detrimental mental health conditions. Maladaptive reactions were contrasted for those that indicated a greater than 12 months’ time-lapse and those who had not.ResultsMore than a third of the women reported in the narrative that at least one year or more had passed since experiencing the miscarriage or abortion. For those women, the median time span between the loss and composing the blog was 4 years with a range of 47 years. Mental health conditions attributed to the reproductive loss by those who reported longer bereavement times included subsequent relationship problems, substance misuse, depression, suicidal ideation, and PTSD. The percent of reported maladaptive issues was more than double for those who reported that a year or more had passed since the loss of the pregnancy.DiscussionGrief reactions following the loss of a pregnancy may be prolonged or delayed for several months which can contribute to adverse biopsychosocial outcomes. Recognition and treatment of maladaptive grief reactions following a pregnancy loss are critical. Screening methods should be enhanced for clinicians in medical office settings to help identify and expedite the appropriate mental health assistance. (shrink)

The allocation of vaccines and therapeutics for Covid‐19 obviously raises ethical questions, and physicians and ethicists have begun to address them. Writers have identified various criteria that should guide allocation decisions, but the criteria often conflict and need to be balanced against one another. This article proposes a model for thinking about how different considerations that are relevant to the distribution of vaccines and scarce treatments for Covid‐19 could be integrated into an allocation procedure. The model employs the construct of (...) a weighted lottery, which is a construct that has been employed in other contexts that involve the distribution of scarce resources. The article highlights the advantages of applying a weighted lottery to the Covid‐19 context and offers an illustration for how it might work in practice. The primary aim of the article is to articulate the structural features of a weighted lottery for this context and to bring out its advantages over other methods for allocating Covid‐19 medications. (shrink)

Headache disorders can be considered as the predominant neurological condition. In the field of neurological diseases, migraine was estimated to cost a total of €27 billion per year for the loss through reduced work productivity in the European Community. Medical data and information in turn provide knowledge based on which physicians make scientific decisions for diagnosis and treatments. It is, therefore, very useful to create diagnostic tools to help physicians make better decisions. This paper is focused on a new (...) hybrid clustering system combining analytic hierarchy process and weighted fuzzy c-means clustering method for diagnosing children with primary headache disorder. The proposed three-stage hybrid diagnosing system is tested on data set collected from hospitalized children in the Clinical Centre of Vojvodina, Novi Sad, Serbia. (shrink)

Since 1980, the number of twin births in the United States has increased 76 percent, and the number of triplets or higher‐order multiples has increased over 400 percent. These increases are due in part to increased maternal age, which is associated with spontaneous twinning. But the primary reason for these increases is that more and more people are undergoing fertility treatment. Despite an emerging (but not absolute) consensus in the medical literature that multiples, including twins, should be (...) a far less frequent outcome of fertility treatment, American clinicians currently practice fertility medicine in ways likely to result in twins and, occasionally, triplets—often, they tell us, at the request of their patients. At first blush, one might conclude that these practice patterns show that patients and their doctors have weighed the risks associated with twins against the benefits of swiftly completing their families and decided that the risks are worth taking. That is, their requests for twins must represent their free and informed choices. But there are reasons to be skeptical of this interpretation, including that the preferences of many patients seem to be very strongly shaped, if not sometimes completely constrained, by concerns about costs—costs that mainly result from the routine exclusion of in vitro fertilization from health insurance coverage. It is quite possible, we believe, that these cost concerns actually undermine the autonomy of fertility patients, pushing many of them to take risks with their health and the health of their hoped‐for future children. (shrink)

In a recent article in this journal, Carl Knight and Andreas Albertsen argue that Rawlsian theories of distributive justice as applied to health and healthcare fail to accommodate both palliative care and the desirability of less painful treatments. The asserted Rawlsian focus on opportunities or capacities, as exemplified in Normal Daniels’ developments of John Rawls’ theory, results in a normative account of healthcare which is at best only indirectly sensitive to pain and so unable to account for the value of (...) efforts of which the sole purpose is pain reduction. I argue that, far from undermining the Rawlsian project and its application to problems of health, what the authors’ argument at most amounts to is a compelling case for the inclusion of freedom from physical pain within its index of primary goods. (shrink)

A deficit in the number of organs available for transplantation persists even with an increase in donation rates. One possible choice of donor for organs that appears under-referred and/or unaccepted is patients with primary brain tumours. In spite of advances in the treatment of high-grade primary central nervous system (CNS) tumours, the prognosis remains dire. A working group on organs from donors with primary CNS tumours showed that the risk of transmission is small and outweighs the (...) benefits of waiting for a normal donor, in survival and organ life-years, with caveats. This paper explores the possibility that, if information on organ donation were made available to patients and their families with knowledge of their inevitable fate, perhaps some will choose to donate. It would be explained that to achieve this, elective ventilation would be performed in their final moments. This would obviate the consent question because of an advance statement. It is accepted that these are sensitive matters and there will be logistic issues. This will need discussion with the public and other professionals, but it could increase the number of donors and can be extrapolated to encompass other primary CNS tumours. (shrink)

The medical treatment of wild animals is an accepted practice in our society. Those who take it upon themselves to treat wildlife are well-intentioned and genuinely concerned about their charges. However, the doctoring of sick animals is of extremely limited value and for the most part based on biological illiteracy. It wastes scarce resources and diverts attention from more worthwhile goals. While it is not wrong to minister to wildlife, it is not right either. The person who refuses (...) to do so has not violated any moral duty and is not necessarily morally callous. The treatment of wildlife is based on the mistaken belief that value lies in individual wild animals rather than the entire ecosystern. The genuine concern of those who doctor wild animals should be channeled in to more constructive directions. (shrink)

The medical treatment of wild animals is an accepted practice in our society. Those who take it upon themselves to treat wildlife are well-intentioned and genuinely concerned about their charges. However, the doctoring of sick animals is of extremely limited value and for the most part based on biological illiteracy. It wastes scarce resources and diverts attention from more worthwhile goals. While it is not wrong to minister to wildlife, it is not right either. The person who refuses (...) to do so has not violated any moral duty and is not necessarily morally callous. The treatment of wildlife is based on the mistaken belief that value lies in individual wild animals rather than the entire ecosystern. The genuine concern of those who doctor wild animals should be channeled in to more constructive directions. (shrink)

The goal of this paper is to review and describe the characteristics and outcomes of ethics consultations on a gastrointestinal oncology service and to identify areas for systems improvement and staff education. This is a retrospective case series derived from a prospectively-maintained database of the ethics consultation service at Memorial Sloan Kettering Cancer Center. The study analyzed all ethics consultations requested for patients on the gastrointestinal medical oncology service from September 2007 to January 2016. A total of 64 patients (...) were identified. The most common primary ethical issue was the DNR order, followed by medical futility. The most common contextual issues were dispute/conflict between staff and family, dispute/conflict intra-family, and cultural/ethnic/religious issues. The majority of ethical issues leading to consultation were resolved ; i.e., the patient, surrogate, and/or healthcare team followed the recommendation of the ethics consultant. 22% had a DNR order prior to the ethics consult and 69% had a DNR order after the consult. In this population of patients on a gastrointestinal oncology service, ethics consultations are most often called regarding patients with advanced cancers and the most common ethical conflicts arose between families and the health care team over goals of care at the end of life, specifically related to the DNR order and perceived futility of continued/escalation of treatment. Ethics consultations assisted with conflict resolution. Conflicts might be reduced with improved communication about prognosis and earlier end of life care planning. (shrink)

PurposeTo examine the contribution of “values-based reasoning” in evaluating older adults’ capacity to make medical decisions.Design and MethodsOlder men with schizophrenia (n=20) or dementia (n=20), and a primary care comparison group (n=19), completed cognitive and psychiatric screening and an interview to determine their capacity to make medical decisions, which included a component on values. All of the participants were receiving treatment at Veterans Administration (VA) outpatient clinics.ResultsParticipants varied widely in the activities and relationships they most valued, (...) the extent to which religious beliefs would influence healthcare decisions, and in ratings of the importance of preserving quality versus length of life. Most participants preferred shared decision making with doctor, family, or both. Individuals with schizophrenia or dementia performed worse than a primary care comparison group in reasoning measured by the ability to list risks and benefits and compare choices. Individuals with dementia performed comparably to the primary care group in reasoning measured by the ability to justify choices in terms of valued abilities or activities, whereas individuals with schizophrenia performed relatively worse compared to the other two groups. Compared to primary care patients, participants with schizophrenia and with dementia were impaired on the ability to explain treatment choices in terms of valued relationships.ConclusionMedical decision making may be influenced by strongly held values and beliefs, emotions, and long life experience. To date, these issues have not been explicitly included in structured evaluations of medical decision-making capacity. This study demonstrated that it is possible to inquire of and elicit a range of healthcare related values and preferences from older adults with dementia or schizophrenia, and individuals with mild to moderate dementia may be able to discuss healthcare options in relation to their values. However, how best to incorporate a values assessment into a structured capacity evaluation deserves further research attention. (shrink)

Next SectionEvidence based medicine is rightly at the core of current medicine. If patients and society put trust in medical professional competency, and on the basis of that competency delegate all kinds of responsibilities to the medical profession, medical professionals had better make sure their competency is state of the art medical science. What goes for the ethics of clinical trials goes for the ethics of medicine as a whole: anything that is scientifically doubtful is, other (...) things being equal, ethically unacceptable. This particularly applies to so called orphaned fields of medicine, those areas where medical research is weak and diverse, where financial incentives are lacking, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health, which investigate complex syndromes such as RSI, whiplash, chronic low back pain, and chronic fatigue syndrome. It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields. Although we agree that this issue deserves more attention as a matter of potential injustice, we want to argue that, in order to do justice to the interplay of heterogeneous factors that is so typical of the orphaned fields, other ethical models than justice are required. We propose the coordination model as a window through which to view the important ethical issues which relate to the communication and interaction of scientists, health care workers, and patients. (shrink)

When consent to medical treatment is described as ‘valid’, it might simply mean that it has a sound basis, or it could mean that it is legally valid. Where the two meanings are regularly interchanged, however, it can lead to aspects of the sound basis or the legal requirements being neglected. This article looks at how the term is used in a range of guidance on consent to treatment and argues for consistency.

In The Netherlands, it is openly acknowledged that the parents' ability to take care of their child plays a role in the decision-making process over administration of life-prolonging treatment to severely defective newborn babies. Unlike other aspects of such decision-making process up until the present time, the ‘ability to take care’ has not received specific attention in regulation or in empirical research. The present study is based on interviews with neonatologists in two Dutch NICUs concerning their definition of the (...) ability to take care and its relevance in non-treatment decisions. All of the respondents think that the ability to take care consists of more than one factor. Most doctors mention the parents' emotional state, social network and cognitive abilities. Some doctors mention the presence of psychological conditions in the parents, their financial situation and physical condition. A few refer to the parents' experience and age, their chances to have another baby and their cultural background. Most doctors think the ability to take care has a secondary relevance in the decision-making process, while the primary concern is assessing the condition of the child. A substantial minority thinks the ability to take care does not play any role, while one doctor thinks it is a factor of primary importance. The study constitutes an important stepping-stone for future research in The Netherlands and elsewhere. (shrink)

Minors are generally considered incompetent to provide legally binding decisions regarding their health care, and parents or guardians are empowered to make those decisions on their behalf. Parental authority is not absolute, however, and when a parent acts contrary to the best interests of a child, the state may intervene. The best interests standard is the threshold most frequently employed in challenging a parent''s refusal to provide consent for a child''s medical care. In this paper, I will argue that (...) the best interest standard provides insufficient guidance for decision-making regarding children and does not reflect the actual standard used by medical providers and courts. Rather, I will suggest that the Harm Principle provides a more appropriate threshold for state intervention than the Best Interest standard. Finally, I will suggest a series of criteria that can be used in deciding whether the state should intervene in a parent''s decision to refuse medical care on behalf of a child. (shrink)

Background:Despite their negative consequences, evidence shows that futile medical treatments are still being provided, particularly to terminally ill patients. Uncovering the reasons behind providing such treatments in different religious and sociocultural contexts can create a better understanding of medical futility and help manage it effectively.Research objectives:This study was undertaken to explore Iranian nurses’ and physicians’ perceptions of the reasons behind providing futile medical treatments.Research design:This was a qualitative exploratory study. Study data were gathered through conducting in-depth semi-structured (...) personal interviews and analyzed using the conventional content analysis method.Participants and research context:Twenty-one nurses and nine medical specialists were recruited purposively from four teaching hospitals affiliated to Tehran University of Medical Sciences.Ethical considerations:This study was approved by the Nursing and Midwifery Research Center and the Research Ethics Committee of Tehran University of Medical Sciences. All participants gave informed consent for the research and that their anonymity was preserved.Findings:The main theme of the study was “having an obligation to provide medical treatments despite knowing their futility.” This theme consisted of three main categories including patients’ and family members’ request for continuing life-sustaining treatments, healthcare professionals’ personal motives, and organizational atmosphere and structure.Discussion and conclusion:Different personal and organizational factors contribute to providing futile medical treatments. Promoting the structure and the function of hospital ethics committees, establishing and developing home care facilities, increasing the number of palliative care centers and hospices, and educating healthcare professionals, patients, and family members about the services and the benefits of such centers can facilitate making wise decisions about continuing or discontinuing treatments which have been labeled as futile. (shrink)

ZusammenfassungDer „Entwurf eines Gesetzes zur strukturellen Weiterentwicklung der Pflegeversicherung“ vom 17. 10. 2007 sieht Regelungen zur Einbeziehung von stationären Pflegeeinrichtungen in die ambulante ärztliche GKV-Versorgung vor. Der vorliegende Beitrag analysiert und bewertet den Ansatz zur „heimärztlichen Versorgung“ unter rechtlichen Aspekten vor dem Hintergrund der Problematik der Psychopharmakaversorgung von Heimbewohnern und schon bestehender Möglichkeiten der Verzahnung der ambulanten ärztlichen und der stationären pflegerischen Versorgung. Das geplante Modell verfolgt das begrüßenswerte Ziel, die gelegentlich als unzureichend beschriebene ambulante ärztliche Betreuung von Pflegebedürftigen in (...) Pflegeheimen zu verbessern, Schnittstellenprobleme abzubauen und gleichzeitig der gesetzlichen Krankenversicherung unnötige Transport- und Krankenhauskosten zu ersparen. Es ist jedoch nur ein rudimentäres Heimarztmodell, da es gerade keine flächendeckende Versorgung der Heimbewohner mit Heimärzten erreichen will. Auch fehlen Anreize für eine Optimierung der ärztlichen und der pflegerischen Zusammenarbeit. Insofern können die Probleme, die sich im Rahmen der Psychopharmakaversorgung von stationär zu pflegenden Heimbewohnern abzeichnen, nur punktuell durch diese Reform verbessert werden. (shrink)