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PubMed2004

How many organs should one patient receive? The ethics of transplantation in the medical school.

BACKGROUND: Interest in the humanities in the medical school is growing; while several medical schools, mainly of Anglo-Saxon background, have developed dedicated courses, the experience in Italy is limited. METHODS: Since the academic year 2000 to 2001, a discussion of ethical problems was implemented in the nephrology course (fourth year of the Medical School of Torino, Italy; overall 6 years). In 2002 to 2003, a case entitled "Retransplantation of Multiple Organs (Prog Transplant 2002)" was discussed in 2 hours of small-group tutorial teaching: a boy received a renal graft at age 5, failed at age 7 due to recurrent glomerulonephritis, required a heart-kidney graft at age 11, and a second heart-kidney graft at 17. Student opinions were gathered by anonymous semistructured questionnaires at the beginning of the lessons as a basis for discussion. RESULTS: Following the lessons all students returned the questionnaires (n = 104). In the absence of competition for allocation, retransplantation was approved by 76.2%, unacceptable for 1% (22.9% uncertain-blank). With a waiting list of 10 patients, the opinions changed: 32.4% approved transplantation, 6.7% didn't approve it, 60.9% were uncertain. A theoretical categorization into deontological or utilitaristic approaches favored the first (41.9% vs 26.7%), with a high prevalence of blank-uncertain (31.5%); 21.9% of the students would change their opinion was that study head of the Transplant Department. CONCLUSION: Ethical aspects of the medical profession have been discussed with interest by medical school students; the high prevalence of uncertain answers and requests to develop specific tools underline the importance of this educational approach.

Humans↗
PubMed1999

Evaluating professionalism in emergency medicine: clinical ethical competence.

While the teaching and assessing of technical skills have been an integral part of residency training, the demonstration of ethical and humanistic skills has been more or less left to chance. Only in the last two decades has the formal teaching of bioethics become an accepted component of Western medical education. In spite of the many ethics lectures, discussions, conferences, and courses, the clinical impact of this educational paradigm shift remains unclear. Most ethics assessments to date are conducted retrospectively by risk managers and attorneys. The few prospective evaluations of trainees have focused on single-researcher observations or student attitude surveys that are fraught with observer and recall biases, respectively. More reliable and valid methods of identifying clinical ethical competence are needed. This paper reviews a variety of evaluative tools and suggests a three-level approach to monitoring the ethical knowledge, capacity, and real-time performance of emergency medicine residents.

Clinical Competence↗
PubMed2003

What motivates minorities to participate in research?

This study investigates factors that facilitate and impede minority participation in medical and scientific research studies. Four focus group sessions involving 18 participants aged 18 to 55 years were conducted. Participants, all members of minority groups, were asked a series of questions about why minorities in the Twin Cities area might or might not participate in medical research. Focus group participants indicated they would be willing to participate as research subjects if study findings were shored with them and their primary care physician and if results would benefit their community. Participants cited 4 major barriers to their participation in research: limited knowledge of health studies, mistrust of researchers, limited community involvement in the design of health studies, and use of invasive procedures. Results from this study suggest that researchers seeking to include minority subjects need to use more participatory or community-centered approaches to research.

Adolescent↗
PubMed2005

Informed consent: does practice match conviction?

The need to obtain consent is an ethical principle and a legal requirement in health care that must be applied in practice. Dentists must give people the appropriate information about treatment options, risks, and benefits so that they are able to make informed choices before giving their free consent to any dental intervention. The British research reported on here supports the view that dentists generally have positive views about informed consent. But the companion program of observation of dentists in the clinic suggests that they do not have a systematic approach to obtaining consent and that patients are often told what is going to be done rather than asked. Dentists must approach informed consent more systematically, recognizing it as an integral part of treatment planning with the patient as developing the communication skills needed to do it well.

Communication↗
PubMed1995

Development of limited sampling strategies for characteristics of a pharmacokinetic profile.

New approaches for empirical and model-based development of constrained, limited sampling strategies for the estimation of one or more characteristics of a pharmacokinetic (PK) profile are evaluated. The methods (i) permit a specification of an overall risk function weighted by each estimation objective, (ii) require only a few sampling times for each of one or more new individuals, (iii) permit tight time constraints, such as those imposed by outpatients, and (iv) recognize variations across individuals, but determine optimal sampling times that are the same for all individuals. The methods are applied to a 4-way crossover pharmacokinetic study of two formulations of cyclosporin G, under fed and fasted conditions, in renal transplant patients. This application used average percentage absolute error for estimating AUC and Cmax with an overall risk function that first put all weight on the error for estimating AUC and second put equal weights on the errors for estimating AUC and Cmax. Empirical and model-based methods identified constrained, 3-point designs with acceptable precision for estimating either AUC alone or AUC and Cmax simultaneously. Model-based sampling times were obtained by software for minimizing a general objective function subject to linear constraints where the objective function was evaluated by computer-intensive sampling under a nonlinear mixed-effects model. The model-based approach permitted a direct comparison of the precision of limited and full sampling strategies.

Cyclosporine↗
PubMed1993

The power of compassion: truth-telling among American doctors in the care of dying patients.

The perceptions of American doctors about their practice regarding truth-telling in the care of dying patients were examined based on semi-structured interviews with 32 physicians in a teaching hospital. The doctors inform patients of their disease using three basic styles; 'telling what patients want to know', 'telling what patients need to know' and 'translating information into terms that patients can take'. These styles are supported by five basic normative principles; 'respect the truth', 'patients rights', 'doctors' duty to inform', 'preserve hope' and 'individual contract between patients and doctors'. These styles and principles suggest that physicians adhere to the recent trends of American medical ethics based on informed consent doctrine, and give the impression that patients have control over obtaining information. But close analysis of their accounts shows that physicians still hold power to control information through their management of the information-giving process. The styles and principles are flexibly interpreted and selectively used in the process so that they facilitate a discourse which justifies, rather than eliminates, the information control. Clinical contexts of information control are analyzed by examining dissimilar manners of providing information about treatment as opposed to prognosis. Physicians give less, and vaguer information about prognosis, citing its uncertainty and lesser relevance to future actions as reasons. Information about treatment is more readily shared in order to counterbalance the negative impact of the news on patients. The analysis reveals that the way doctors control information is closely related to the way they handle aspects of the reality of clinical practice, such as physicians' own emotional coping, institutional and legal constraints, and power relationships among patients, doctors and other care-givers. Situating the findings in the historical context of normative discourse in American medicine, discussion focuses on the issues of trust and power of doctors. The humanistic role of the doctor, although suppressed in the currently dominant, contractual ethical framework, is still powerful in doctors' narratives. It expresses doctors' commitment to patients while preserving their authority. Implications of the individualistic approach to the doctor-patient relationship are also discussed.

Adult↗
PubMed2000

Bridging cultural differences in medical practice. The case of discussing negative information with Navajo patients.

BACKGROUND: Cultural differences between doctors and their patients are common and may have important implications for the clinical encounter. For example, some Navajo patients may regard advance care planning discussions to be a violation of their traditional values. OBJECTIVE: To learn from Navajo informants a culturally competent approach for discussing negative information. DESIGN: Focused ethnography. SETTING: Navajo Indian reservation, northeast Arizona. PARTICIPANTS: Thirty-four Navajo informants, including patients, traditional healers, and biomedical health care providers. MEASUREMENT: In-depth interviews. MAIN RESULTS: Strategies for discussing negative information were identified and organized into four stages. Assessment of patients is important because some Navajo patients may be troubled by discussing negative information, and others may be unwilling to have such discussions at all. Preparation entails cultivating a trusting relationship with patients, involving family members, warning patients about the nature of the discussion as well as communicating that no harm is intended, and facilitating the involvement of traditional healers. Communication should proceed in a caring, kind, and respectful manner, consistent with the Navajo concept k'é. Reference to a third party is suggested when discussing negative information, as is respecting the power of language in Navajo culture by framing discussions in a positive way. Follow-through involves continuing to care for patients and fostering hope. CONCLUSIONS: In-depth interviews identified many strategies for discussing negative information with Navajo patients. Future research could evaluate these recommendations. The approach described could be used to facilitate the bridging of cultural differences in other settings.

Arizona↗
PubMed1999

Assessment of competence to complete advance directives: validation of a patient centred approach.

OBJECTIVE: To develop a patient centred approach for the assessment of competence to complete advance directives ("living wills") of elderly people with cognitive impairment. DESIGN: Semistructured interviews. SETTING: Oxfordshire. SUBJECTS: 50 elderly volunteers living in the community, and 50 patients with dementia on first referral from primary care. MAIN OUTCOME MEASURES: Psychometric properties of competence assessment. RESULTS: This patient centred approach for assessing competence to complete advance directives can discriminate between elderly persons living in the community and elderly patients with dementia. The procedure has good interrater (r=0.95) and test-retest (r=0.97) reliability. Validity was examined by relating this approach with a global assessment of competence to complete an advance directive made by two of us (both specialising in old age psychiatry). The data were also used to determine the best threshold score for discriminating between those competent and those incompetent to complete an advance directive. CONCLUSION: A patient centred approach to assess competence to complete advance directives can be reliably and validly used in routine clinical practice.

Dementia↗
PubMed1983

Medical ethics education: a professor of religion investigates.

A study was carried out in a large teaching hospital to ascertain the current view of members of ten ward teams in regard to certain problems in the field of medical ethics. The investigator accompanied each team on their morning rounds and sat in on their discussions. At the end of each week he interviewed the faculty member, residents, intern, and medical students who comprised that team. Responses to these fifty open-ended interviews were grouped into categories that seemed natural to the data. These were tabulated and commented upon. The conclusions drawn were that there is an urgent need for ethical discourse in medical education, but that there are certain built-in difficulties in bringing this about in a significant way. Focus of attention upon critical incidents that come up in the normal cycle of ward rounds appeared to be the optimum approach to take.

Bioethical Issues↗
PubMed2000

Development of an instrument to investigate parents' perceptions of research with newborn babies.

Neonatal intensive care nurses are often involved in research protocols as investigators, research assistants or staff nurses implementing the protocol and providing support and explanations to families. It is important, therefore, that nurses have information about parents' understanding of and attitudes towards the research process. The purpose of this study was to begin an exploration of parents' perceptions about research with newborn babies through the development and validation of a survey instrument. The questionnaire included: demographic questions; scaled items about research with newborn babies; scenarios describing research studies that varied in degree of risk and benefit to the newborn baby; questions about parents' willingness to enrol their newborn baby in the studies described; and questions regarding circumstances under which consent should be sought. Content and face validity were established by an expert panel and a pilot test conducted with a small group of health care professionals and lay persons. A convenience sample of 231 parents of newborn babies completed the final version of the questionnaire. Factor analysis revealed seven factors corresponding to issues identified in the literature, providing evidence of construct validity. Parents appeared to have no difficulty in completing the instrument and all questions were answered by the majority of participants. It was concluded that the questionnaire had adequate psychometric properties and that a mixed method approach can be fruitful in exploring sensitive issues.

Adult↗
PubMed1984

Falling through the cracks: poverty, insurance coverage, and hospital care for the poor, 1980 and 1982.

About one-third of the nation's poor lack insurance--public or private--against the costs of illness. Data from 1980 and 1982 show that a patchwork of state and local government charitable grants, and the disparate efforts of hospitals to provide free care, cannot mend the national "safety net." A prudent short-run approach to modifying charity care is advanced, although the long-run necessity for insuring the uninsured is inevitable.

Charities↗
PubMed1983

The effect of repeated testing upon comprehension of informed consent materials by elderly volunteers.

One hundred elderly adults (mean = 71.3 years of age, range = 59-88 years) in four WAIS vocabulary subgroups (less than 40, 40-49, 50-59, greater than or equal to 60) served in an evaluation of the effects of using multiple comprehension test trials to improve informed consent procedures. Participants in Group I were given a single comprehension test and feedback before signing consent documents, while those in Group II were provided with as many as three comprehension trials, if necessary. All participants were tested for memory of the information 2-3 weeks later. Results indicated that both comprehension and memory performance varied directly with vocabulary level. The multi-trial approach improved comprehension scores at all vocabulary levels, but had no effect upon memory.

Aged↗
PubMed1996

Reassessing medical students' willingness to treat HIV-infected patients.

BACKGROUND: Past research has demonstrated that some physicians do not feel obligated to care for patients infected with the human immunodeficiency virus (HIV). This study sought to characterize the attitudes that affect medical students' willingness to treat HIV-infected patients and to determine which attitudes are most amenable to intervention. METHOD: All 414 matriculating medical students at three Chicago schools were surveyed in 1994. After reliability-testing the attitudinal scales, the authors created a predictive model by using multiple regression analysis. RESULTS: A total of 297 (72%) of the matriculating students responded. Ninety-two percent of the students agreed that patients with HIV would be welcome in their medical practices. As in past studies, a strong sense of professional obligation was associated with willingness to treat, and fear of infection and homophobia were associated with decreased willingness to treat. The authors' measure of concern about social stigma was also associated with decreased willingness. Together, these factors accounted for 53% of the variance in the Willingness to Treat scale. CONCLUSION: In addition to confirming the predictors found in previous studies, this study demonstrated that perceived social stigma is a measurable predictor of decreased willingness to treat (with the understanding that willingness to treat is influenced by both personal and social factors). A comprehensive approach, not only in curriculum design but also in admission and policy, might better prepare students to treat HIV-infected patients.

Acquired Immunodeficiency Syndrome↗
PubMed1980

A comparative study of the handling of confidentiality.

Increasing concern with the problem of confidentiality has prompted the authors to examine factors associated with the handling of confidentiality among a sample of psychiatrists, psychologists, and internists. Significant differences were found among the three groups of clinicians. The nature of professional training and the predominant approach to treatment were found to be related to attitudes toward confidentiality, as was previous professional experience with socially threatening behavior. Implications of the findings are discussed.

Adult↗
PubMed1998

Some AIDS-related policy issues and nursing students' willingness to provide AIDS care.

Two thirty three diploma students from a Nursing School, in Delhi were surveyed anonymously to seek their opinion on some AIDS-related policy issues and willingness to provide AIDS care. More than one fourth of students opinionated that health personnel should be given a choice to refuse care to the AIDS patients and an equal proportion felt that authorities should be empowered to terminate the services of such personnel. Majority were in favour of making HIV testing compulsory for various high risk groups, indoor patients and health workers. Perceiving the risk of HIV infection, 41.2% students felt that girls might not opt for nursing career, whereas few (10.7%) were considering even to leave the profession. However, majority (58-72%) were willing to nurse the high risk individuals, if adequate training and preventive measures were provided in the health care settings. The study implies framing of an AIDS policy taking in to consideration the views of health professionals and imparting comprehensive training to the nursing students in order to promote a humane approach towards AIDS care.

AIDS Serodiagnosis↗
PubMed1995

Conflicting attitudes to corneal and organ donation: a study of nurses' attitudes to organ donation.

The demand for transplantable organs and tissues is steadily increasing and action is necessary to improve the organ and tissue donation rates. Previous research has suggested that nurses have a substantial influence on the rates of donation in the clinical area. Nurses (N = 150) were asked to complete a number of measures to assess positive and negative attitudes towards cadaveric organ donation, with 112 (74.6%) responding. The findings identified conflicting attitudes particularly in relation to corneal donation; 25% of the respondents would not donate their corneas. Reasons given included fear of disfigurement, religious factors such as the need to see into the next life, and dislike of the thought of donation of eyes but without knowing why. The majority of the respondents were in favour of donation generally and many carried or had signed donor cards. Nurses are usually the professionals who have the most contact with the patient in the clinical and are therefore able to identify potential donors. It seems likely that nurses with conflicting attitudes to donation are less likely to undertake the emotional costs involved when relatives of potential donors are approached re donation, than those who have more positive attitudes.

Adult↗