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PubMed2004

Implementing the Institute of Medicine's recommended curriculum content in schools of public health: a baseline assessment.

In September 2003, the Association of Schools of Public Health administered an online survey to representatives of all 33 accredited US schools of public health. The survey assessed the extent to which the schools were offering curriculum content in the 8 areas recommended by the Institute of Medicine: communication, community-based participatory research, cultural competence, ethics, genomics, global health, informatics, and law/policy. Findings indicated that, for the most part, schools of public health are offering content in these areas through many approaches and have incorporated various aspects of a broad-based ecological approach to public health education and training. The findings also suggested the possible need for greater content in genomics, informatics, community-based participatory research, and cultural competence.

Curriculum↗

PubMed1993

Informed consent for clinical anaesthesia research.

Most surgical patients are first seen by an anaesthetist after admission to hospital, either the evening before or on the day of surgery. Some medical ethicists believe that an approach by an anaesthesia researcher made after admission is unethical because the hospital itself is a coercive environment, and patients have insufficient time for reflection or consultation. Others believe that an approach prior to admission may be an invasion of the patient's privacy and confidentiality. The implications of these views for anaesthesia researchers may not be apparent to research ethics boards (REBs). To determine current practice, a questionnaire concerning the membership and function of REBs and the time of obtaining informed consent was sent to each research representative of the 16 Canadian university departments of anaesthesia. Membership of REBS was similar, but not identical, in all centres. Most representation was from medical disciplines. Consent was generally obtained following the patient's admission to hospital. In one centre, the REB always requested informed consent to be obtained before the patient's admission to the hospital. Surgeons had no involvement with consent for anaesthesia research in 14 centres while in the other two they gave permission for their patients to be studied and informed patients of the potential approach by anaesthesia researchers. We conclude that it is ethically acceptable to obtain informed consent for most low-risk clinical anaesthesia research after the patient's admission to hospital.

Anesthesiology↗

PubMed1991

Attitudes towards care of the dying: a questionnaire survey of general practice attenders.

In order to determine the views of General Practice attenders on death and dying, a survey was conducted using a questionnaire with nine questions on aspects of death and dying. There were 4117 respondents with an average age of 36.4 years, who attended 10 general practices. A control group of 100 patients was employed. There was a stated preference for management by the General Practitioner and a wish to die in the home. An honest approach by doctors was called for and the greatest fear concerning death was that of leaving the family. A subgroup of people who stated that they had close personal experience of death or dying, amplified most of these findings.

Attitude↗

PubMed1992

A survey method for investigating ethical decision making in family practice.

BACKGROUND: The tension between respect for patient autonomy versus concern for patient welfare is a challenging ethical issue for physicians. The purpose of this research was to describe a method for analyzing ethical decisions and to report the results of a survey of ethical decision making among family physicians. METHODS: We developed a survey instrument that used simulated case scenarios, each of which posed an ethical dilemma. The ethical problems on the survey included the extent to which diagnostic information should be revealed to patients, the extent to which physicians should become involved in patients' life-style issues, and how to deal with patients' family problems. We mailed the questionnaire to 1,300 US family physicians. RESULTS: Six hundred seventy-four physicians responded. Respondents did not deal with the simulated ethical problems in a uniform manner and often tended to respond more to specific details of a case rather than the overall ethical dilemma posed. Physicians who chose a course of action giving patients more control were motivated by factors that showed respect for patient autonomy. On the other hand, physicians who chose a course of action giving patients less control were not motivated by factors suggesting a concern for patient welfare. CONCLUSIONS: Based on responses to simulated case scenarios, family physicians did not demonstrate a uniform approach but rather a more contextual one. Respect for patient autonomy was linked to family physicians' reported courses of action.

Adult↗

PubMed1988

Attitudes of genetic counselors: a multinational survey.

Of 1,053 medical geneticists in 18 nations 677 (64%) returned questionnaires on their views on the importance of seven goals of genetic counseling, the appropriateness of five directive/nondirective approaches to counseling, and their choices of action in four situations involving directive/nondirective counseling. The majority (92%-94%) regarded nondirective approaches as appropriate; their views on both goals and approaches were similar to those reported in an earlier survey of 205 genetic counselors in the United States. In clinical situations involving presentation of reproductive options to carriers of disorders not diagnosable prenatally, 74%-85% would present contraception, sterilization, taking one's chances, artificial insemination donor (AID), or adoption as options even if not asked; 66% would present in vitro fertilization (IVF) with a donor egg; and 46% (67% in the United States) would present surrogate motherhood. In regard to three situations involving fetuses with low-burden disorders (Turner syndrome, XYY, and a possible small neural tube defect), 84%-88% would counsel nondirectively. Stepwise logistic regression analyses on professional and personal background variables showed that gender was related, cross-nationally, to self-reported directiveness in counseling, with men more likely than women to regard directive approaches as appropriate, more likely to give advice about fetuses with low-burden disorders, and more likely to present either IVF with donor egg or surrogate motherhood as options. Social and ethical implications of this widespread acceptance of nondirective counseling are discussed.

Allied Health Personnel↗

PubMed1987

An evaluation of empirical antibiotic therapy in febrile neutropenic patients.

A prospective study was undertaken to determine the effectiveness of an empirical antibiotic therapy regimen in 34 neutropenic patients undergoing bone marrow transplantation or remission-induction chemotherapy for leukaemia. Throughout the study period a total of 90 pyrexial episodes were monitored in which organisms designated to be pathogens were isolated from blood cultures on 38 occasions. The response rate to the combination of a ureidopenicillin with gentamicin fell sharply from 50% during patients' first pyrexial episodes to zero during the third and subsequent episodes. The preponderance of Gram-positive bacteria and the high overall resistance of bacterial isolates to these antibiotics have led us to reconsider our approach to empirical therapy and to include antibiotics with greater activity against Staphylococcus epidermidis. The emergence of fungi as a major cause of morbidity in patients with prolonged neutropenia underlines the necessity to introduce early empirical antifungal therapy in this group of patients.

Adolescent↗

PubMed1986

Last days: a study of the quality of life of terminally ill cancer patients.

Behavior of a number of Quality of Life measures gathered from two samples of terminal cancer patients over the last weeks of their lives are reported. Samples represent patients in the 26 hospices participating in a nationwide U.S. demonstration project and patients in the palliative care units of two Montreal hospitals. The U.S. data reported are quality of life measures made by a lay principal care person (PCP) or trained interviewer; the Montreal measures were made by both an attending doctor and an attending nurse. The general finding, as expected, is one of increasing deterioration in quality of life, with accelerated deterioration between 3 and 1 week of death. Pain follows a somewhat different pattern than other measures. More patients are in either of the extreme categories at an earlier point in time than found for other measures, and there are fewer changes as death is approached. Finally, about 20% of the patients do not fall into extremely low quality of life categories, even in the week prior to death.

Activities of Daily Living↗

PubMed1987

Interpreting survival rates for the treatment of decompensated diabetes: are we saving too many lives?

Discussion of the case of a patient admitted to hospital with decompensated diabetes revealed a conflict in attitudes to resuscitation of the patient from that disorder and from cardiac arrest. A survey was sent to 200 diabetologists and 200 cardiologists in the United Kingdom, asking about their management of diabetes and their therapeutic approaches to cardiac arrest for 3 elderly patients admitted with severe decompensated diabetes. The response rate was poor (27%) but the answers showed that all 3 patients were more likely to be resuscitated from decompensated diabetes than from cardiac arrest. Possible reasons for a different approach to the two conditions are discussed, and suggestions are put forward for a greater involvement by patients in decisions about future resuscitation.

Aged↗

PubMed2001

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

OBJECTIVE: To discover and explore the factors that result in the "false optimism about recovery" observed in patients with small cell lung cancer. DESIGN: A qualitative observational (ethnographic) study in 2 stages over 4 years. SETTING: Lung diseases ward and outpatient clinic in a 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 on x-ray films. This optimism tended to vanish when the tumor 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 by their physical deterioration and partly through contact with fellow patients in a more advanced stage of the illness who were dying. False optimism about recovery was the result of an association between physicians' activism and patients' adherence to the treatment calendar and to the "recovery plot," which allowed them to avoid acknowledging explicitly what they should and could know. The physician 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 physician and patient require an active, patient-oriented approach by the physician. Perhaps solutions have to be found outside the physician-patient relationship itself--for example, by involving "treatment brokers."

Aged↗

PubMed2005

Communicating with realism and hope: incurable cancer patients' views on the disclosure of prognosis.

PURPOSE: To identify preferences for the process of prognostic discussion among patients with incurable metastatic cancer and variables associated with those preferences. PATIENTS AND METHODS: One hundred twenty-six (58%) of 218 patients invited onto the study participated. Eligible patients were the consecutive metastatic cancer patients of 30 oncologists, who were diagnosed within 6 weeks to 6 months before recruitment, over 18 years of age, and without known mental illness. Patients completed a postal survey measuring patient preferences for the manner of delivery of prognostic information, including how doctors might instill hope. RESULTS: Ninety-eight percent of patients wanted their doctor to be realistic, provide an opportunity to ask questions, and acknowledge them as an individual when discussing prognosis. Doctor behaviors rated the most hope giving included offering the most up to date treatment (90%), appearing to know all there is to know about the patient's cancer (87%), and saying that pain will be controlled (87%). The majority of patients indicated that the doctor appearing to be nervous or uncomfortable (91%), giving the prognosis to the family first (87%), or using euphemisms (82%) would not facilitate hope. Factor analysis revealed six general styles and three hope factors; the most strongly endorsed styles were realism and individualized care and the expert/positive/collaborative approach. A range of demographic, psychological, and disease factors were associated with preferred general and hope-giving styles, including anxiety, information-seeking behavior, expected survival, and age. CONCLUSION: The majority of patients preferred a realistic and individualized approach from the cancer specialist and detailed information when discussing prognosis.

Adult↗

PubMed1992

What creates the dilemma in ethical dilemmas? Examples from psychological practice.

Twenty psychologists were interviewed about an ethical dilemma that they had found to be particularly difficult to resolve. In just under half of the cases the dilemma involved a perceived conflict of ethical principles (e.g., the welfare of the consumer vs. the right to privacy). In the other cases, the psychologists were prevented from following an ethically prescribed course of action by some nonethical consideration such as contractual obligation, legal requirement, or the demands of an employer. We discuss the implications of these two sorts of dilemmas for psychological practice and make some suggestions for proactive approaches to ethical problem solving.

Adolescent↗

PubMed1999

The relation between physician experience and patterns of care for patients with AIDS-related Pneumocystis carinii pneumonia: results from a survey of 1,500 physicians in the United States.

STUDY OBJECTIVES: To determine whether physician experience and specialty influence the approach to care of AIDS patients with pneumonia, we surveyed physicians about their management of possible Pneumocystis carinii pneumonia (PCP) infection. DESIGN, SETTING, PARTICIPANTS: A postal survey was sent to a random sample of 1,500 internists and family physicians in the United States drawn from the American Medical Association master file who were identified by a pharmaceutical marketing company as having written prescriptions for AIDS-related agents in the previous year. MEASUREMENTS AND RESULTS: The survey had a 53% response rate. Physicians more experienced in AIDS care were more likely to advocate diagnostic bronchoscopy over initiation of empiric anti-PCP therapy for HIV-infected patients with undiagnosed pulmonary infiltrates (odds ratio [OR], 1.4 for a patient with mild severity of illness [p = 0.02]; OR, 1.7 for a severely ill patient [p < 0.001]). Physician specialty and fee-for-service reimbursement were independently associated with higher rates of bronchoscopy, with internists favoring bronchoscopy more frequently than family physicians. High-experience providers and internists also predicted better clinical outcomes for the hypothetical patients. CONCLUSIONS: Our findings extend the observations about HIV experience and PCP prophylaxis to the setting of diagnosis and treatment. Physicians with higher levels of experience with AIDS, internists, and physicians reimbursed as fee-for-service providers are more likely to support diagnostic confirmation of PCP than empiric treatment approaches.

AIDS-Related Opportunistic Infections↗

PubMed1992

Estimation of heterogeneous within-herd variance components using empirical Bayes methods: a simulation study.

Genetic evaluation using BLUP can accommodate heterogeneous variances if the necessary variance components are known; this may require estimation of variance components within each heterogeneous subclass. Properties of sire and residual variance estimates obtained by an empirical Bayes approach, which combines within-herd and prior estimates, were examined via simulation. Prior estimates were obtained using REML across herds, as if variances were homogeneous. Convergence was improved by incorporation of prior information such that variance component estimates could be obtained in within-herd situations for which a REML algorithm failed to converge. Accuracy of sire variance estimates was greatest when both within-herd and prior information were used, but improvement in accuracy of residual variance estimates associated with incorporation of prior information was minimal. Correlations between sires' standardized true transmitting abilities and PTA that used empirical Bayes variance estimates were larger than those obtained when heterogeneity was ignored. Proportions of sires selected, based on standardized PTA, from environments with differing genetic and residual variances became more uniform as the relative weight placed on within-herd data in variance estimation increased. Thus, useful variance component estimates can be obtained within individual herds by using empirical Bayes methods with across-herd estimates as prior information; this may allow prediction of breeding values that are less influenced by heterogeneous variances.

Algorithms↗

PubMed1991

Teaching intubation skills using newly deceased infants.

This prospective study was designed to (1) test the hypothesis that the majority of families of newly dead infants in a tertiary neonatal intensive care unit would consent to their infants' being intubated for teaching purposes, (2) determine factors related to family consent, and (3) determine the effects of participation on resident physicians and respiratory therapists. Family consent for intubation was requested following 44 (80%) of the 55 deaths that occurred during the 10-month study period. Of these requests, 32 (73%) were granted. Proportionately more white than black families consented and consent was positively related to autopsy permission. Fifty-three (75%) of 71 trainees completed a mailed questionnaire after their first intubation experience. Although each respondent found the experience helpful, many reported mixed feelings categorized as doubt about participating, apprehension and discomfort, respect for the body, appreciation for the opportunity, a sense of achievement, and feelings of comfort knowing that consent had been obtained. These findings confirm our initial hypothesis and suggest that (1) newly dead infants can be a valuable resource for teaching intubation skills, and (2) others considering a similar approach need to be aware of and sensitive to trainees' feelings.

Adolescent↗

PubMed1980

For the 1980s: how small is too small?

Because of the poor survival rates among sick infants weighing less than 750 gm and because of the poor quality of life of surviving infants, a less aggressive approach seems appropriate. Obstetricians, pediatricians, and neonatologists must explain the risks and benefits of intensive care frankly and honestly to families and accept their own limitations.

Canada↗

PubMed1989

Attitudes of hospital doctors in Wales to use of intravenous fluids and antibiotics in the terminally ill.

Decisions concerning the use of intravenous fluids and antibiotics in terminally ill patients are regularly made by hospital doctors, but there is little record of staff attitudes and current practice in Britain. A questionnaire was therefore distributed to 833 Welsh hospital doctors, citing the case of a hypothetical terminally ill patient and asking questions about medical management. Of the 448 (54%) doctors who replied, 346 (77%) had managed a similar patient recently. Intravenous fluids would be administered by 238 (53%), with 206 of these (87%) resiting the cannula as required and 62 (26%) resorting to a central venous line if there was no alternative. With increasing age and seniority doctors become conservative in their approach. Nearly all claimed that 'ensuring the patient's comfort' was the reason for their decision. Only 72 (16%) would use antibiotics if the patient became pyrexial. The results suggest that British doctors are divided in their approach to the medical management of terminally ill patients and there is a need for greater discussion and training so that all the issues involved are fully appreciated.

Anti-Bacterial Agents↗

PubMed1987

Treatment refusal among forensic inpatients.

Although the United States Supreme Court has not offered a definite opinion, some states have established the qualified right of involuntarily committed patients to refuse treatment. Controversy continues between psychiatry and law over what procedural protections should be provided to patients when therapists seek to override nonemergency refusal of treatment. The authors review Oregon's administrative approach and its application to the treatment refusal of 33 state hospital forensic patients. Patient characteristics, refusal patterns, and implications of treatment refusal are also described.

Adult↗

PubMed2002

Talking about money: how primary care physicians respond to a patient's question about financial incentives.

Patients sometimes express concern about the influence of "perverse" financial incentives on their care. We recruited a convenience sample of 101 primary care physicians and obtained information on their compensation. Then we audiotaped them as they role-played a response to a videotaped mock patient who asked them how they were paid and how their method of compensation affected clinical decisions. Overall, 36% of the physicians did not give enough information in their role-play response to allow an independent determination of how they were paid. Adopting a broad spectrum of attitudes and approaches, nearly every physician avoided discussing the role of incentives and stressed instead that he or she could be trusted under any circumstance.

Adult↗