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PubMed1997

A comparison of Japanese and American psychiatrists' attitudes towards patients wishing to die in the general hospital.

BACKGROUND: The attitudes of the psychiatrists in Japan and the US were compared in order to investigate their ideas on whether patients in general medical hospitals who have a desire to die should be allowed to do so or be assisted in this regard, and whether they require psychiatric evaluation and intervention, and the cultural influences on these attitudes. METHODS: Japanese and American general hospital psychiatrists' attitudes towards the reasonability of suicide, physician-assisted suicide, and removal of life supports under various medical and psychosocial situations were compared. Seventy-two American and 62 Japanese psychiatrists' data were collected using the Suicidal Attitudes Inventory. RESULTS: The majority of both American and Japanese psychiatrists agreed that there may be times when suicidal ideation or completed suicide in med-surg patients could be reasonable. Significantly more Japanese psychiatrists responded with some agreement to the reasonability of suicide when one is unable to fulfill social role expectations, and had more concern about causing suicidal ideation by informing terminal patients of their diagnosis. CONCLUSIONS: The results indicate that psychiatrists' attitudes towards the relationship of psychopathology with suicidal ideation, the effect of depression, and other cultural factors on the desire to die in the medically ill are issues that need better clarification among both the medical profession as well as within society. Looking at how other societies handle these matters may help to understand one's own approach to them.

Adult↗

PubMed2001

Prenatal screening, ethics and Down's syndrome: a literature review.

This article reviews the literature on prenatal screening for Down's syndrome. To be evidence based, medicine and nursing have to take account of research evidence and also of how this evidence is processed through the influence of prevailing social and moral attitudes. This review of the extensive literature examines how appropriate widely-held understandings of Down's syndrome are, and asks whether or not practitioners and prospective parents have access to the full range of moral arguments and social evidence on the matter. Highly valued ideals of justice, personal autonomy, parental choice, women's control over their reproduction and of avoiding harm can all tend towards negative rather than neutral approaches to Down's syndrome. This article considers how ethics and prenatal screening policies and practice that take greater account of social evidence of disability could use moral arguments that inform rather than determine the choices of people who use prenatal services.

Bioethical Issues↗

PubMed1998

An enquiry into a combined approach for nursing ethics.

A definitive theory for ethical decision making in nursing is still only conjecture. The literature confirms that there have been numerous examinations of ethical decision making in nursing, with most proposing either the justice or the care orientation, or a combination of both. In the absence of a definitive theory, this exploratory work sets out, via grounded theory, to shed some light on the methods used every day by nurses to make ethical decisions in the clinical area. The data show that some factors, such as doctors, colleagues and the organization, profoundly influence ethical decision making. The informants used both care and justice to formulate decisions, which is known as the combined approach. As a result of these findings, this article concludes with tentative suggestions and recommendations for practice.

Beneficence↗

PubMed1991

Substituted judgment: how accurate are proxy predictions?

Substituted judgment has been proposed as a method of promoting the autonomy of the mentally incapacitated patient, but little is known about the accuracy of surrogate decision makers in reflecting the true wishes of patients. In this study, surrogate decision makers' views (those of primary care providers and close family members) were compared with the decisions of currently competent chronically ill elderly patients, using a hypothetic cardiopulmonary resuscitation scenario under circumstances of current health and progressive dementia. Concordance between patients and their surrogates was evaluated by assessing percent agreement, kappa coefficient (for concordance beyond chance), and directionality of discrepant responses. Most patient respondents chose to be resuscitated in both scenarios. Although patients predicted that both their physicians (90%) and family members (87%) would accurately represent their wishes, neither family members nor physicians, in fact, were able to adequately predict patients' wishes in both scenarios (kappa less than or equal to 0.3 in all scenarios; percent agreement range, 59% to 88%). Few patients had ever discussed their resuscitation preferences with either their family member (16%) or their physician (7%). These results cast doubt on the usefulness of a strict substituted judgment standard as an approach to medical decision making for patients with diminished mental capacity.

Aged↗

PubMedDate not supplied

Determinants of physician unwillingness to offer medical abortion using mifepristone.

PURPOSE: We sought to identify factors associated with contemplating versus not contemplating offering medical abortion with mifepristone among physicians not opposed to it. METHODS: We analyzed data from a Kaiser Family Foundation survey of a nationally representative sample of 790 American obstetrician/gynecologists and primary care physicians. Our study sample consisted of 419 physicians who were not personally opposed to medical abortion and could be classified as not actively considering (precontemplation) or actively considering (contemplation) offering mifepristone. We conducted multivariate logistic regression to predict being unlikely to offer mifepristone (i.e., in the precontemplation stage of change). PRINCIPAL FINDINGS: In 2001, 1 year after U.S. Food and Drug Administration (FDA) approval, 5% of physicians surveyed were offering mifepristone. Among the 750 physicians not offering mifepristone, 57% were not opposed. Of those not opposed, 74% reported that they were unlikely to offer mifepristone in the next year (precontemplation) as compared to 23% who might offer it (contemplation). Independent predictors of being in the precontemplation stage were being a primary care versus OB/GYN physician (odds ratio [OR] 3.29, p = .02), being in private versus hospital-based practice (OR 2.40, p = .03), and lacking concerns about FDA regulations (OR 2.06, p = .01) or violence and protests (OR 1.93, p = .03) as barriers to offering mifepristone. CONCLUSIONS: For precontemplation-stage physicians, the most efficient strategy for increasing the availability of medical abortion may be to design programs that emphasize clinical benefits and feasibility to stimulate interest in the procedure. For contemplation-stage physicians, the optimum approach may be one that helps to overcome barriers associated with FDA regulations and concerns about violence and protests.

Abortifacient Agents, Steroidal↗

PubMed2005

Recruiting donors for autopsy based cancer research.

The use of human tissue for scientific research is a highly sensitive issue. A lack of confidence in patient recruitment is one reason for the failure of many studies to be funded and it is important therefore that recruitment procedures are as effective and sympathetic as possible. The authors recruited patients with uveal melanoma into a postmortem study investigating tumour latency in this cancer. Two approaches were used--firstly a direct approach when patients attended clinic and secondly an initial approach by mail followed by telephone contact. In the first year of study the authors had a take up rate of 88.5%, significantly higher than the average rate of 40% quoted by the National Institute for Clinical Excellence (NICE). Key features are a sympathetic personal approach by experienced oncology nurses, the provision of clear information, and the inclusion of the next of kin in the recruitment procedure.

Autopsy↗

PubMed1999

African American men, prostate cancer early detection examination use, and informed decision-making.

It is well known that African American men are more likely to be diagnosed with metastatic prostate cancer than White men. Racial variation in the use of prostate cancer early detection modalities (ie, digital rectal examination [DRE] and prostate-specific antigen [PSA] testing) has been suggested as a major reason for this differential. Several factors may help to explain the reported low levels of DRE and PSA test utilization among African American men, including background sociodemographic characteristics, medical history, and cognitive and psychosocial perceptions. In this review, the impact of these characteristics on prostate cancer early detection examination utilization is explored. Findings from studies showing race-related differences in cognitive and psychosocial factors are presented. Preparatory education for informed decision-making is suggested as an approach to help minimize racial differences in cognitive and psychosocial factors that influence the use of prostate cancer early detection modalities. The need to facilitate informed decision-making along the continuum of care is highlighted.

Black or African American↗

PubMed2003

Knowledge, attitude and practice of private medical practitioners in Calabar towards post-abortion care.

This study examined the knowledge, attitude and practice of private medical practitioners in Calabar on abortion, post-abortion case and post-abortion family planning. Forty eight private practitioners who were proprietors of private clinics in the city were interviewed using a structured questionnaire. The results showed that 22.9% of the doctors routinely terminate unwanted pregnancies when requested to do so by women, while 83.3% of them treat women who experience complications of unsafe abortion. The major reasons given by some of the doctors for not terminating unwanted pregnancies were religious, moral and ethical considerations rather than respect for the Nigerian abortion law. Only 18.2% of the doctors use standard procedures such as manual vacuum aspiration (MVA) for the management of patients with abortion and abortion complications. A good number of them did not routinely practice integrated post-abortion family planning and STDs management. There is need for a comprehensive programme of retraining of private medical practitioners in Calabar on the principles and practices of safe abortion, post-abortion care and family planning. These aspects of reproductive health need to be integrated into the medical training curricula in Nigeria. It is believed that this approach would help reduce the present high rate of abortion-related morbidity and mortality in Nigeria.

Abortion, Induced↗

PubMed1983

Life of advanced cancer patients after knowing the nature of their own disease: a personal experience of seven cases.

To seven patients suffering from advanced cancer who wished to know what their disease was and whose families supported them in their wish, I informed them of the name of the disease and how advanced their case was. After being told they had cancer, not only did the patients become more cheerful to and more trustful of their families, but also they came to place greater confidence in us' doctors and nurses. Their wish to live was strong and they all wanted to have their anticancer therapy continued. At the terminal stage, four of them merely wanted to have their pain relieved, and two of them became depressive when the symptoms of approaching death became evident. But judging from the total clinical course of the seven carefully screened patients, I believe that informing them of the true nature of the disease brought about favorable results.

Adult↗

PubMed1995

Mandated choice. A plan to increase public commitment to organ donation.

OBJECTIVES: To estimate the impact of mandated choice--a system that requires competent adults to decide prospectively whether or not they wish to be organ donors when they die--on public commitment to organ donation; and to explore who is best suited to provide consent--the family or the individual? DESIGN: A national, random-digit telephone survey conducted by the Gallup Organization in July 1993. PARTICIPANTS: A representative sample (n = 1002) of adults (aged 18 years and older) living in homes with telephones in the continental United States. RESULTS: Although the majority of respondents had given at least some thought to organ donation, only 25% had carefully considered this issue. Overall, 30% had decided to donate, but 58% were undecided and only 38% had made their wishes known to a family member. Yet the vast majority (82%) believes that the best way to obtain consent is for each adult to decide for himself or herself, rather than leaving this decision for the family. Under mandated choice, which is designed to encourage such self-determination, 63% would sign up to donate, 24% would not, and 13% were unsure. CONCLUSIONS: Only a small fraction of the US public is currently committed to organ donation and relatively few people have carefully considered and communicated their wishes regarding this important issue. Therefore, the difficult question of consent is often left for the family. Yet most people believe that ideally all adults should answer this question for themselves, in contrast to our present family-oriented approach, but consistent with the design of mandated choice. If mandated choice became law, it appears that most adults would sign up to donate, thereby increasing the pool of desperately needed committed donors.

Family↗

PubMed2003

Public health ethics: teaching survey and critical review.

The last decade has witnessed development of the new field of public health ethics, as well as growing emphasis on the importance of ethics education to both students and graduates of the health care professions. Using a topic-based interpretation of public health ethics this paper presents a questionnaire survey of the nature and content of teaching of public health ethics to medical undergraduates and public health postgraduate students in the United Kingdom. Completed questionnaires were returned by 76.9% (20/26) of medical schools and 76.7% (23/30) of institutions teaching postgraduate public health courses. Public health ethics was described as being taught in 75% of medical schools and 52% of institutions providing postgraduate education. However, in both types of location the content and nature of teaching was patchy and often minimal. If medical schools and postgraduate institutions are serious about improving the discussion and teaching of ethical issues in public health, there will need to be considerable investment and commitment, accompanied by creativity and imagination. In parallel, the debate about the meaning of, and approaches to, public health ethics needs to be broadened and enriched. The topic-based interpretation of public health ethics has limitations. Alternatives are explored and critically reviewed.

Curriculum↗

PubMed2000

Collusion in doctor-patient communication about imminent death: an ethnographic study.

OBJECTIVE: To discover and explore the factors that result in "false optimism about recovery" observed in patients with small cell lung cancer. DESIGN: A qualitative observational (ethnographic) study in two stages over four years. SETTING: Lung diseases ward and outpatient clinic in university hospital in the Netherlands. PARTICIPANTS: 35 patients with small cell lung cancer. RESULTS: "False optimism about recovery" usually developed during the (first) course of chemotherapy and was most prevalent when the cancer could no longer be seen in the x ray pictures. This optimism tended to vanish when the tumour recurred, but it could develop again, though to a lesser extent, during further courses of chemotherapy. Patients gradually found out the facts about their poor prognosis, partly because of physical deterioration and partly through contact with fellow patients who were in a more advanced stage of the illness and were dying. "False optimism about recovery" was the result an association between doctors' activism and patients' adherence to the treatment calendar and to the "recovery plot," which allowed them not to acknowledge explicitly what they should and could know. The doctor did and did not want to pronounce a "death sentence" and the patient did and did not want to hear it. CONCLUSION: Solutions to the problem of collusion between doctor and patient require an active, patient oriented approach from the doctor. Perhaps solutions have to be found outside the doctor-patient relationship itself - for example, by involving "treatment brokers."

Attitude to Health↗

PubMed2005

Research advance directives: protection or obstacle?

OBJECTIVE: This study assessed how many adults completed a research advance directive and the preferences indicated on the completed forms. METHOD: The authors analyzed all 2,371 adults admitted as inpatients to the NIH Clinical Center from March 14 to Sept. 13, 2000. RESULTS: Overall, 11% of adult inpatients completed a research advance directive. Of those who specified preferences, 13% were not willing to participate in future research should they become unable to consent, 76% were willing to participate in research that might help them, 49% were willing to participate in research that would not help them and posed minimal risk, and 9% were willing to participate in research that would not help them and posed greater than minimal risk. CONCLUSIONS: Proposals to allow cognitively impaired adults to participate in research only with a formal advance directive could block important research. More flexible approaches should be considered to protect these individuals.

Adult↗

PubMed2003

Ethical dilemmas related to the HIV-positive person in the workplace.

This study's objectives were: (1) to describe and explore the ethical dilemmas surrounding the HIV-positive person in the workplace in South Africa; and (2) to describe the Rational Interaction for Moral Sensitivity (RIMS) approach as a possible mechanism for solving these ethical dilemmas. A qualitative, exploratory and descriptive research design was used. The target populations were HIV-positive employees and occupational health nurses working for a South African company. Data collected through individual HIV-positive employee interviews and occupational health nurse workgroups were analysed. The ethical dilemmas were conceptualized and described within the theoretical framework of the principles of ethics, namely, autonomy, beneficence, justice and confidentiality. To elicit a solution to the dilemmas, the data were recontextualized using the RIMS approach, a group decision-making strategy designed for the business environment.

Absenteeism↗

PubMed2003

Shared treatment decision making: what does it mean to physicians?

PURPOSE: Physicians are urged to practice shared treatment decision making (STDM), yet this concept is poorly understood. We developed a conceptual framework describing essential characteristics of a shared approach. This study assessed the degree of congruence in the meanings of STDM as described in the framework and as perceived by practicing physicians. METHODS: A cross-sectional survey questionnaire was mailed to eligible Ontario medical and radiation oncologists and surgeons treating women with early-stage breast cancer. Open-ended and structured questions elicited physicians' perceptions of shared decision making. RESULTS: Most study physicians spontaneously described STDM using characteristics identified in the framework as essential to this concept. When presented with clinical examples in which the decision-making roles of physicians and patients were systematically varied, study physicians overwhelmingly identified example 4 as illustrating a shared approach. This example was deliberately constructed to depict STDM as defined in the framework. In addition, more than 85.0% of physicians identified as important to STDM specific patient and physician roles derived from the framework. These included the following: the physician gives information to the patient on treatment benefits and risks; the patient gives information to the physician about her values; the patient and physician discuss treatment options; both agree on the treatment to implement. CONCLUSION: Substantial congruence was found between the meaning of STDM as described in the framework and as perceived by study physicians. This supports use of the framework as a conceptual tool to guide research, compare different treatment decision-making approaches, clarify the meaning of STDM, and enhance its translation into practice.

Attitude of Health Personnel↗

PubMed2004

Improving risk disclosure during the consent process.

OBJECTIVES: To provide guidance about the risks which should be disclosed to patients and documented during the consent process. METHODS: The Delphi Consensus Technique was used to decide what constitutes mandatory risk disclosure for three index procedures. Documentation of risk on consent forms was audited and compared to these locally agreed standards. A four stage strategy for change was undertaken following which practice was reviewed. RESULTS: Mean mandatory risk documentation rose from 61.2% (95% CI: 58.1-64.4) pre-intervention, to 78.1% (95% CI: 72.6-83.6) post-intervention (ccc2; P < 0.001). CONCLUSIONS: Although we demonstrated some benefit from this simple approach, the need for pragmatic means of achieving and sustaining complete discussion and documentation of risks across all surgical interventions based on universally accepted standards remains.

Humans↗

PubMed1998

Moving toward policy development on assigning publication credit for oncology nurses' contributions to scholarly and scientific work.

The policy implications of a 1996 national nursing survey on the allocation of publication credit form of this paper. An earlier article (Butler & Ginn, 1997) describes and analyzes the outcome of the survey; the purpose here is to draw on that analysis, and on the relevant literature, to propose a starting place for discussion within the specialty of oncology and the nursing profession regarding assignment of credit for various contributions to collaborative scholarly work. After identifying the growing need for such a discussion and briefly highlighting the findings of the survey, the paper goes on to examine unacceptable practices in scholarly work and identify issues which should be resolved before collaborative work is undertaken. The final portion of the paper makes tentative suggestions as to principles and guidelines which might be applied to avoid disputes about the value of different contributions to a collaborative project. It is emphasized that the intention is not to advocate acceptance of the guidelines suggested here, but to create sufficient interest so that an approach to allocation of publication credit may be developed which will be consistent and relevant to the needs of the nursing profession.

Attitude of Health Personnel↗

PubMed2001

Do researchers feel an LREC hinders research?

BACKGROUND: All medical professionals in the UK who wish to undertake clinical trials involving NHS patients must first obtain ethical approval. Although Local Research Ethics Committees (LRECs) play a crucial role, few studies have attempted to determine what researchers think about the effectiveness of their ethics committee. OBJECTIVE: To explore researchers' views as to the effectiveness or otherwise of their LREC. SUBJECTS: 78 experienced medical researchers. FINDINGS: While most researchers did not feel that the LREC made it more difficult to carry out their research, without good cause, a substantial minority was critical of the Committee, with many feeling that its approach was overly pedantic. CONCLUSION: There may be a need for greater dialogue between ethics committees and researchers, so that researchers understand why committees ask for certain information, and committees are aware of problems their requirements may cause.

Attitude↗