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PubMed1995

Advance care planning: eliciting patient preferences for life-sustaining treatment.

Patient autonomy is a guiding principle in medical decision-making in America. This is challenging when patients become mentally incapacitated and cannot express their preferences. Advance care planning (ACP) addresses this challenge. ACP is a deliberative and communicative process that helps people formulate and communicate preferences for future medical care in the event of mental incapacity. Advance directives are mechanisms for communicating and/or documenting ACP, and are either instructional (e.g. statement of treatment preferences in living wills) or proxy types (e.g. appointment of another person to speak on the patient's behalf). ACP discussions between patients and health care providers and patient-orientated educational ACP materials often ignore insights from 2 related activities, health promotion and human information processing. More effective ACP should occur with greater attention to the concepts of stages of change and self-efficacy, the Health Belief Model, and the necessary requisites for cognitive integration.

Advance Care Planning↗
PubMed2003

Feminist ethics and menopause: autonomy and decision-making in primary medical care.

The construction of menopause as a long-term risk to health and the adoption of discourses of prevention has made necessary a decision by women about medical treatment; specifically regarding the use of hormone replacement therapy. In a study of general practitioners' accounts of menopause and treatment in Australia, women's 'choice', 'informed decision-making' and 'empowerment' were key themes through which primary medical care for women at menopause was presented. These accounts create a position for women defined by the concept of individual choice and an ethic of autonomy. These data are a basis for theorising more generally in this paper. We critically examine the construct of 'informed decision-making' in relation to several approaches to ethics including bioethics and a range of feminist ethics. We identify the intensification of power relations produced by an ethic of autonomy and discuss the ways these considerations inform a feminist ethics of decision-making by women. We argue that an 'ethic of autonomy' and an 'offer of choice' in relation to health care for women at menopause, far from being emancipatory, serves to intensify power relations. The dichotomy of choice, to take or not to take hormone replacement therapy, is required to be a choice and is embedded in relations of power and bioethical discourse that construct meanings about what constitutes decision-making at menopause. The deployment of the principle of autonomy in medical practice limits decision-making by women precisely because it is detached from the construction of meaning and the self and makes invisible the relations of power of which it is a part.

Australia↗
PubMed1984

Confidentiality in crisis counseling: a philosophical perspective.

Crisis interventionists frequently confront a moral dilemma when violating client trust seems necessary if self-destructive behavior is to be prevented. Two fundamental moral values conflict in such cases: concern for client welfare and respect for client rights and autonomy. Each of these values is grounded in one of two important Western ethical traditions: Utilitarianism and Kantian Formalism, respectively. Following critical examination of each of these theories, attention is given to a series of hypothetical cases involving the confidentiality dilemma.

Confidentiality↗
PubMed1996

Respect for autonomy: is it always paramount?

Following the argument proposed by Tschudin in 1986 that many nurses do not have the skills for ethical decision-making, this article identifies and discusses one ethical problem from practice. The problem concerns an extremely obese patient who refuses to be moved by a hoist. The nurse acquiesce to the patient's wishes and she is moved manually by four members of staff. The issues identified for discussion are: the paramountcy of the principle of respect for the patient's autonomy; the rights and obligations of the nurses; and the justification for influencing patient choice. The approach used by the ward nurses is analysed and the value of using an ethical decision-making model is considered.

Aged↗
PubMedDate not supplied

The role of commercial non-related living kidney transplants.

The motivation for dialysis patients to seek early, even pre-emptive, kidney transplantation from living donors is discussed. In most countries both the waiting time and the numbers of patients awaiting kidney transplantation are increasing. Local geopolitics in Jerusalem have produced a unique window to observe present transplant practices which include widespread international marketing of kidneys from paid living donors. These have been subject of media admonitions and total rejection by professional organizations. In a modern world, traditional medical paternalism to both donors and patients should be balanced by rights for individual autonomy. Since patients, donors and medical professionals are already participating in illicit organ trading, is it not time for us to seriously consider the ethical and logistic implications of legalizing financial remuneration for kidney donation?

Aged↗
PubMed1992

HIV testing: an ethical analysis.

As the epidemic of the human immunodeficiency virus continues to grow, the relationship between patients and health care workers is being tainted with fear and mistrust. The demand for mandatory testing of health care providers has caused many of us to assess our basic values of autonomy, beneficence, nonmaleficence, and justice. Is our "right to privacy" more important than our "right to know"? This article will analyze some of the legal, moral, and ethical issues to be considered in identifying possible alternatives and a justified solution to this dilemma.

AIDS Serodiagnosis↗
PubMed2004

Memantine enhances autonomy in moderate to severe Alzheimer's disease.

BACKGROUND: Alzheimer's disease (AD) is the leading cause of dementia and its course renders patients functionally disabled. Memantine is the first drug to demonstrate a clinical benefit in the treatment of patients with moderately-severe to severe AD. OBJECTIVES: Our objective was to illustrate the benefits of memantine on functional disability. METHODS: We classified 252 patients from a randomised 28-week clinical trial of memantine vs placebo according to their Activities of Daily Living capabilities measured by the ADCS-ADLsev scale. The scale was divided into two sub-scores: basic and instrumental. The relevance of this classification was validated by comparing clinical and socio-demographic parameters between the different autonomy classes (autonomous and dependent). The effect of memantine was estimated by using a logistic regression model on the autonomy status of patients at week 28, controlling for confounding factors (Observed Cases analysis). RESULTS: Our results showed that dependent patients (n = 106) had significantly longer disease duration, poorer cognition, greater severity, more behavioural alterations and higher total societal costs compared with autonomous patients (n = 146). When controlling for autonomy and severity at baseline, memantine-treated patients were three times more likely [Odds Ratio (OR) = 3.03; 95% Confidence Intervals (CI) = (1.38, 6.66)] to remain autonomous after 28 weeks. Analysis of the Treated Per Protocol set and the use of Last Observation Carried Forward analyses confirmed this finding. CONCLUSIONS: Memantine enhances autonomy in patients with moderately-severe to severe AD by increasing the probability of their remaining autonomous, therefore delaying transition to the dependent stage.

Activities of Daily Living↗
PubMed1990

The futures of physicians: agency and autonomy reconsidered.

The corporatization of U.S. health care has directed cost containment efforts toward scrutinizing the clinical decisions of physicians. This stimulated a variety of new utilization management interventions, particularly in hospital and managed care settings. Recent changes in fee-for-service medicine and physicians' traditional agency relationships with patients, purchasers, and insurers are examined here. New information systems monitoring of physician ordering behavior has already begun to impact on physician autonomy and the relationship of physicians to provider organizations in both for-profit and 'not-for-profit' sectors. As managed care practice settings proliferate, serious ethical questions will be raised about agency relationships with patients. This article examines health system dynamics altering the historical agency relationship between the physician and patient and eroding the tradiational autonomy of the medical profession in the United States. The corporatization of medicine and the accompanying information systems monitoring of physician productivity is seen to account of such change, now posing serious ethical dilemmas.

Cost Control↗
PubMed2001

The role of CNSs in promoting elderly patients' autonomy in long-term institutions: problems and implications for nursing practice and research.

Autonomy has become an important focus within healthcare. Elderly patients, however, are often denied the right to independent decision making on grounds of incompetence and incapacity. In long-term institutions there are several ways in which the clinical nurse specialist can promote the autonomy of elderly patients. This article provides an overview of the concept of autonomy and discusses some of the problems in its realization in long-term nursing institutions. It also outlines strategies for supporting autonomy in elderly patients and concludes with a discussion of the implications of autonomy to nursing practice and research.

Age Factors↗
PubMedDate not supplied

Factors influencing homelessness in women.

The specific aims of the article were to: (i) compare childhood experiences of intimacy and autonomy as they occurred in the families of origin of women who have and women who have not experienced homelessness; (ii) compare social support, reciprocity, and conflict as they occurred in the childhood support networks and in the current support networks of women who have and women who have not experienced homelessness; (iii) examine the relationships between intimacy and autonomy in families of origin and the social support networks from childhood of women who have and women who have not experienced homelessness. Descriptive correlational design: 255 women were interviewed to determine levels of intimacy, autonomy, social support, reciprocity, and conflict in childhood relationships. The ANCOVA models for each of support, reciprocity, and conflict indicated a significant group effect. The post-hoc analysis for support indicated that the homeless group was significantly lower in support and reciprocity and significantly higher in conflict than the never-homeless groups. The never-homeless, never-abused group scored significantly higher on autonomy and intimacy than the homeless or the never-homeless, abused groups. This study demonstrates the significance of families of origin and learning how to develop and utilize support systems in preventing or reducing homelessness.

Adult↗
PubMed2003

What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics.

OBJECTIVE: Contemporary ethical accounts of the patient-provider relationship emphasise respect for patient autonomy and shared decision making. We sought to examine the relative influence of involvement in decisions, confidence and trust in providers, and treatment with respect and dignity on patients' evaluations of their hospital care. DESIGN: Cross-sectional survey. SETTING: Fifty one hospitals in Massachusetts. PARTICIPANTS: Stratified random sample of adults (N=27 414) discharged from a medical, surgical, or maternity hospitalisation between January and March, 1998. Twelve thousand six hundred and eighty survey recipients responded. MAIN OUTCOME MEASURE: Respondent would definitely be willing to recommend the hospital to family and friends. RESULTS: In a logistic regression analysis, treatment with respect and dignity (odds ratio (OR) 3.4, 99% confidence interval (CI) 2.8 to 4.2) and confidence and trust in providers (OR 2.5, CI 2.1 to 3.0) were more strongly associated with willingness to recommend than having enough involvement in decisions (OR 1.4, CI 1.1 to 1.6). Courtesy and availability of staff (OR 2.5, CI 2.1 to 3.1), continuity and transition (OR 1.9, CI 1.5 to 2.2), attention to physical comfort (OR 1.8, CI 1.5 to 2.2), and coordination of care (OR 1.5, CI 1.3 to 1.8) were also significantly associated with willingness to recommend. CONCLUSIONS: Confidence and trust in providers and treatment with respect and dignity are more closely associated with patients' overall evaluations of their hospitals than adequate involvement in decisions. These findings challenge a narrow emphasis on patient autonomy and shared decision making, while arguing for increased attention to trust and respect in ethical models of health care.

Adolescent↗
PubMed2004

Autonomy and job satisfaction for a sample of Greek teachers.

Analysing the relation between Job Satisfaction and Autonomy in a sample of 300 Greek teachers (114 men and 186 women, 28 to 59 years old) from primary and secondary schools, showed statistically significant positive correlations between Job Satisfaction and Autonomy. Particularly, Autonomy was correlated with Job Itself (.21), Supervision (.22), and the Organizational as a Whole (.27), aspects of Job Satisfaction. Findings are in line with previous studies conducted in different cultural contexts. Percent common variance accounted for is small.

Adult↗
PubMed2005

Variation in perceived competence, glycemic control, and patient satisfaction: relationship to autonomy support from physicians.

There is considerable variation in care provided to patients with diabetes related to metabolic control, preventive services, and degree of patient-centered support. This study evaluates the relation of self-determination theory (SDT) constructs of clinician autonomy support, and patient competence to glycemic control, depressive symptoms, and patient satisfaction from baseline surveys of 634 patients of 31 Colorado primary care physicians participating in a program to improve diabetes care. Spearman correlations of autonomy support from one's clinician with patient competence, HbA1c, depressive symptoms and satisfaction were significant (R = -0.11 to 0.55, P < 0.005). Structural equation modeling demonstrated that autonomy support was significantly related to perceived competence, depressive symptoms, patient satisfaction, and indirectly to glycemic control. Perceived competence was significantly related to depressive symptoms, patient satisfaction and glycemic control. Further, the motivation constructs from SDT accounted for 5% of the variance in glycemic control, 8% of the variance in depression, and 42% of the variance in patient satisfaction. Quality improvement efforts need to pay greater attention to patient competence, satisfaction, and depression, in addition to glycemic control. Clinician autonomy support was found to be reliably measured and moderately correlated with psychosocial and biologic outcomes related to diabetes self-management. These results suggest training clinicians to increase their support of patient autonomy may be one important avenue to improve diabetes outcomes.

Adult↗
PubMed2001

Relational narratives of the self.

The prevailing view of the self in contemporary Western culture is of the autonomous, separate individual. This article considers shifts toward a more relational view in thinking about the self, in developmental psychology and in therapy, especially family therapy. From diverse perspectives this relational narrative of the self is explored, highlighting relational formulations about autonomy, power, and connection/disconnection. Therapeutic approaches that are grounded in a relational narrative are considered. Finally, this article explores, through clinical vignettes, the impact on individuals and their significant others when they shift to a more relational view of the self in their own lives.

Anecdotes as Topic↗
PubMed1992

Community health and ethical theory: implications for holistic nursing.

A conceptual shift from Enlightenment philosophies to communitarian virtues is discussed. Epidemics and preventing disease spread are used as a basis for discussing the major bioethical concepts beneficence, justice, respect for autonomy, and Moskop's principle of restrictive measures. The addition of the concept of community and communitarian virtues to the ethical analysis is discussed. Holistic nurses are challenged to develop and employ morally sound rationale for ethical decisions.

Beneficence↗
PubMedDate not supplied

Ethics in the locker room: the challenges for team physicians.

Team physicians act as occupational physicians in many traditional ways. However, they face unique ethical challenges when caring for athletes. Sports physicians must be cognizant of special aspects of the doctor-patient relationship, as well as issues related to informed consent, autonomy, and confidentiality. Conflicts of interest with players themselves, as well as with team management, are common. Team physicians must act professionally and maintain ethical principles, even in the high-pressure, high-performance world of athletics.

Athletic Injuries↗
PubMed1986

Ethical aspects of the physician surplus: implications for family practice.

Higher costs, increasing technology, and more physicians are the three predominant influences facing medicine today. These three forces in turn present three groups of ethical issues for physicians: competition and changed fiscal incentives, effects of organized practice on autonomy and confidentiality, and the problems of the interface between primary and consultant physicians. Family physicians must learn to adapt their practices in ethical ways to the rapid changes that are occurring. Thoughtful insight is essential to the process.

Clinical Competence↗