RESUMO
AbstractPurpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools. METHOD: An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses. RESULTS: Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most (n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer (n = 37, 60%) provided faculty training for teaching ethics. CONCLUSIONS: Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices.
Assuntos
Currículo , Ética Médica , Faculdades de Medicina , Humanos , Escolaridade , Ética Médica/educaçãoRESUMO
PURPOSE: Use of the electronic health record (EHR) during face-to-face clinical encounters affects communication, and prior research has been inconclusive regarding its effect. This survey study assessed health care practitioner use of EHR-specific communication skills and patient and practitioner experiences and attitudes regarding EHR use during clinical encounters. METHODS: For this US-based study, we distributed previously validated surveys to practitioners and adult patients (aged >18 years) at academic primary care practices from July 1, 2018 through August 31, 2018. The electronic practitioner survey was completed first; a paper survey was administered to patients after appointments. Descriptive statistics were calculated, and the Cochran-Armitage test was used to assess for associations between key variables. RESULTS: The practitioner response was 72.9% (43/59); patient response, 45.2% (452/1,000). Practitioners reported maintaining less eye contact (79.1%), listening less carefully (53.5%), focusing less on patients (65.1%), and visits feeling less personal (62.8%). However, patients reported that practitioners provided sufficient eye contact (96.8%) and listened carefully (97.0%); they disagreed that practitioners focused less on them (86.7%) or that visits felt less personal (87.2%). Patients thought EHR use was positive (91.7%); only one-third of practitioners (37.2%) thought that patients would agree with that statement. Practitioners reported stress, burnout, and a lack of sufficient time for EHR documentation. CONCLUSIONS: A discrepancy existed in this study between patient and practitioner experiences and attitudes about EHR use, which appeared to negatively affect the experience of health care practitioners but not patients. Organizations should adopt formal strategies to improve practitioner experiences with EHR use.
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Esgotamento Profissional , Registros Eletrônicos de Saúde , Adulto , Comunicação , Documentação , Humanos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Geographic variation in health care spending is typically attributed to differences in patient health status and provider practice patterns. While medicolegal considerations (i.e., "defensive medicine") anecdotally impact health care spending, this phenomenon is difficult to measure. The purpose of this study was to explore the association between the medicolegal environment and Medicare costs for diabetes and associated conditions of interest to vascular surgeons. Specifically, we hypothesized that an adverse medicolegal environment is associated with higher per capita Medicare costs for diabetic patients. METHODS: Medicare data including the most recent (2018) Medicare Geographic Variation Public Use Files and Chronic Conditions Data Files were linked to National Practitioner Data Bank files from the preceding 5 years (2013-2017), in addition to the US census data and American Medical Association workforce statistics. The state-level medicolegal environment was characterized by K-means clustering across a panel of metrics related to malpractice payment magnitude and prevalence. Per capita Medicare spending for diabetes was compared across 5 distinct medicolegal environments. Costs were standardized and risk-adjusted to account for known geographic variation in health care costs and patient population. Analysis of variance was applied to unadjusted data, followed by multivariate regression modeling. Readmission rates, per capita imaging studies, per capita tests, per capita procedures, and lower extremity amputation rates were compared between the least litigious quintile from the K-means clustering and the 2 most litigious quintiles. RESULTS: The median unadjusted Medicare per capita expenditure on diabetic patients was $15,963 ($14,885-$17,673), ranging from $13,762 (Iowa) to $21,865 (D.C.). A 1.6-fold variation persisted after payment standardization. Cluster analysis based on malpractice-related variables yields 5 distinct medicolegal environments, based on litigation frequency and malpractice payment amounts. Per capita spending on diabetes varied, ranging from $15,799 in states with low payments and infrequent litigation to $18,838 in states with the most adverse medicolegal environment (P < 0.05). After cost standardization and risk adjustment with multiple linear regression, malpractice claim prevalence (per 100 physicians) remained an independent predictor of states with the highest diabetes mellitus spending (P = 0.022). Moreover, diabetic patients in states with adverse medicolegal environments had more procedures, imaging studies, and readmissions (P < 0.05 for all) but did not have significant differences in amputation rates compared to less litigious states. CONCLUSIONS: An adverse medicolegal environment is independently associated with higher health care costs but does not result in improved outcome (i.e. amputation rate) for diabetic Medicare beneficiaries. Across states, a 1% increase in lawsuits/100 physicians was associated with a >10% increase in risk-adjusted standardized per capita costs. These findings demonstrate the potential contribution of "defensive medicine" to variation in health care utilization and spending in a population of interest to vascular surgeons.
Assuntos
Diabetes Mellitus , Medicare , Humanos , Estados Unidos/epidemiologia , Idoso , Resultado do Tratamento , Gastos em Saúde , Custos de Cuidados de Saúde , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologiaRESUMO
The Patient Self Determination Act (PSDA) of 1991 brought much needed attention to the importance of advance care planning and surrogate decision-making. The purpose of this law is to ensure that a patient's preferences for medical care are recognized and promoted, even if the patient loses decision-making capacity (DMC). In general, patients are presumed to have DMC. A patient's DMC may come under question when distortions in thinking and understanding due to illness, delirium, depression or other psychiatric symptoms are identified or suspected. Physicians and other healthcare professionals working in hospital settings where medical illness is frequently comorbid with depression, adjustment disorders, demoralization and suicidal ideation, can expect to encounter ethical tension when medically sick patients who are also depressed or suicidal request do not resuscitate orders.
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Tomada de Decisões , Leucemia Linfoide/psicologia , Ordens quanto à Conduta (Ética Médica)/ética , Pensamento , Idoso de 80 Anos ou mais , Comunicação , Humanos , Leucemia Linfoide/complicações , Masculino , Patient Self-Determination Act , Ordens quanto à Conduta (Ética Médica)/legislação & jurisprudência , Estados UnidosRESUMO
OBJECTIVE: Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians' attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus. DESIGN, SETTING, PARTICIPANTS: A survey of resident/fellow physicians and internal medicine attendings at an academic medical center, May to August 2013. MEASUREMENTS: We used a 24-item, internet-based survey assessing physician-respondents' demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected. MAIN RESULTS: A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/fellows. Only 32 percent of the respondents indicated that a surrogate's consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate's objection. Those who self-reported as "knowledgeable" about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VA-ECMO over a surrogate's objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005). CONCLUSIONS: Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians' hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study.
Assuntos
Atitude do Pessoal de Saúde , Tomada de Decisões , Oxigenação por Membrana Extracorpórea , Médicos , Suspensão de Tratamento/ética , Adulto , Feminino , Humanos , Masculino , Procurador , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Despite increased awareness of the value of discussing patients' goals of care, advance directives, and code status as part of the surgical informed consent process, the actual outcomes and risks of cardiopulmonary resuscitation (CPR) remain poorly defined among some subsets of surgical patients. Thus, in an effort to generate an evidence base for communication about shared decision making and informed consent for vascular surgery patients and their surrogates, we defined the incidence, risks, and outcomes of postoperative cardiac arrest after primary vascular surgery procedures. METHODS: The 2007 to 2010 National Surgical Quality Improvement Program data were queried to develop a multi-institutional database of patients undergoing vascular surgery (N = 123,581). Univariate analyses and multivariate logistic regression were used to identify crude and adjusted risk factors for postoperative cardiac arrest requiring CPR and to assess outcomes. RESULTS: Postoperative cardiac arrest requiring CPR was seen in 1234 of 123,581 patients (1.0%) after vascular surgery at a mean of 7.2 ± 2 days. The 30-day mortality was 73.4% compared with 2.7% among patients who did not arrest (P < .001). Of CPR survivors, 102 (12.1%) were still hospitalized at 30 days. Patient variables that were most predictive of postoperative cardiac arrest included dependent functional status (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.3-3.6; P < .001), dialysis dependence (OR, 2.7; 95% CI, 2.3-3.2; P < .001), emergent case (OR, 2.2; 95% CI, 1.9-2.5; P < .001), and preoperative ventilator dependence (OR, 2.0; 95% CI, 1.5-2.7; P < .001). Procedures associated with the highest risk included thoracic aortic surgery (OR, 6.9; 95% CI, 4.8-9.9; P < .001), open abdominal procedures (OR, 3.7; 95% CI, 3.1-4.4; P < .001), axillary-femoral bypass (OR, 2.1; 95% CI, 1.3-3.2; P = .001), and peripheral embolectomy (OR, 1.5; 95% CI, 1.2-1.9; P = .002). At least one major complication preceded cardiac arrest in 47.7% of patients including sepsis (23.5%), renal failure (14.5%), and myocardial infarction (12.1%). Patients with do not resuscitate orders were significantly less likely to undergo CPR (OR, 0.59; 95% CI, 0.39-0.93; P = .021). CONCLUSIONS: Patients undergoing vascular surgery who suffer a postoperative cardiac arrest frequently die in spite of receiving CPR; for those who survive, there is likely to be prolonged hospitalization and significant morbidity. These data provide an evidence base for discussing goals of care, advance directives, and code status with vascular surgery patients and their surrogates. Further research into how to best communicate risk, to elicit patient preferences, and to engage in shared decision making is needed.
Assuntos
Parada Cardíaca/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Técnicas de Apoio para a Decisão , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Seleção de Pacientes , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/mortalidadeRESUMO
BACKGROUND: Patients with Do Not Resuscitate (DNR) orders may still be offered surgery that aims to prolong or improve quality of life. The widely accepted approach of "required reconsideration" mandates that patients and surgeons discuss perioperative risks and expected outcomes in the context of the patient's values and preferences. However, surgical outcomes in this patient population have not been well-defined. The objectives of this study are to assess outcomes in DNR patients undergoing major vascular procedures, and develop an evidence basis for informed, shared decision-making. METHODS: Patients undergoing common major vascular procedures were identified in the 2007-2010 National Surgical Quality Improvement Project databases. DNR patients were defined as those with an active DNR order within 30 days before surgery. Demographics, comorbidities, procedural details, and complications were compared with those without DNR orders. To isolate the impact of DNR status, multivariate regression and 1:1 propensity score matching were used to compare outcomes between DNR patients and a non-DNR cohort of comparably high-risk patients. RESULTS: Of 110,279 patients undergoing major vascular surgery, 1,565 (1.4%) had active DNR orders 30 days preceding surgery. DNR patients were more likely to be functionally dependent (69% vs. 15%; P < 0.0001), over 80 years of age (53% vs. 20%; P < 0.001), and suffer from a variety of cardiac, pulmonary, and systemic comorbidities. The most common procedures in DNR patients were major amputation (38.4%), lower extremity bypass (20%), and peripheral thromboembolectomy (11.7%). Unadjusted 30-day mortality was significantly higher among DNR patients (21% vs. 3.4%; P < 0.001). After 1:1 propensity score matching, with the 2 cohorts differing only with respect to DNR status, perioperative mortality remained significantly higher among DNR patients (21% vs. 13%; P < 0.01). There was a trend toward reduced cardiopulmonary resuscitation in patients with recent DNR (1.7% vs. 2.6%; P = 0.07). CONCLUSIONS: DNR patients are at high risk for major complications and mortality after vascular surgery procedures. Compared with a matched cohort of "high-risk" non-DNR patients, those with DNR orders suffered equivalent rates of postoperative morbidity, but markedly increased mortality. This suggests that DNR status, independent of comorbidities and perioperative complications, may increase the risk of "failure to rescue." These findings have implications not only for risk adjustment, but also provide an evidence basis for shared decision-making in challenging circumstances.
Assuntos
Preferência do Paciente , Seleção de Pacientes , Ordens quanto à Conduta (Ética Médica) , Procedimentos Cirúrgicos Vasculares , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar , Distribuição de Qui-Quadrado , Comorbidade , Bases de Dados Factuais , Feminino , Nível de Saúde , Humanos , Masculino , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidadeRESUMO
OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiopulmonary support offers survival possibilities to patients who otherwise would succumb to cardiac failure. Often referred to as "a bridge to recovery," involving a ventricular assist device or cardiac transplantation, this technology only affords temporary cardiopulmonary support. Physicians may have concerns about initiating VA-ECMO in patients who, in the absence of recovery or transfer to longer-term therapies, might assert religious or cultural objections to the terminal discontinuation of life-sustaining therapy (LST). We present a novel case of VA-ECMO use in an Orthodox Jewish woman with potentially curable lymphoma encasing her heart to demonstrate the value of anticipating and preemptively resolving foreseeable disputes. PATIENT: A 40-year-old Hasidic Orthodox Jewish woman with lymphoma encasing her right and left ventricles decompensated from heart failure before chemotherapy induction. The medical team, at an academic medical center in New York City, proposed VA-ECMO as a means for providing cardiopulmonary support to enable receipt of chemotherapy. Owing to the patient's religious tradition, which customarily prohibits terminal discontinuation of LST, clinical staff asked for an ethics consultation to plan for initiation and discontinuation of VA-ECMO. INTERVENTIONS: Meetings were held with the treating clinicians, clinical ethics consultants, family, religious leaders, and cultural liaisons. Through a deliberative process, VA-ECMO was reconceptualized as a bridge to treatment and not as an LST, a designation assigned to the chemotherapy on this occasion, given the mortal threat posed by the encasing tumor. CONCLUSION: Traditional religious objections to the terminal discontinuation of LST need not preclude initiation of VA-ECMO. The potential for disputes should be anticipated and steps taken to preemptively address such conflicts. The reconceptualization of VA-ECMO as a bridge to treatment, rather than as an LST, can allow patients with objections to the terminal discontinuation of LST to receive interventions, such as chemotherapy, that might otherwise be precluded by critical physiology.
Assuntos
Oxigenação por Membrana Extracorpórea/ética , Cuidados para Prolongar a Vida/ética , Linfoma/patologia , Religião e Medicina , Adulto , Tratamento Farmacológico , Feminino , Insuficiência Cardíaca/patologia , Humanos , Judeus , Judaísmo , Linfoma/tratamento farmacológico , PacientesRESUMO
Normothermic Regional Perfusion, or NRP, is a method of donated organ reperfusion using cardiopulmonary bypass or a modified extracorporeal membrane oxygenation (ECMO) circuit after circulatory death while leaving organs in the dead donor's corpse. Despite its potential, several key ethical issues remain unaddressed by this technology.
Assuntos
Confiança , Humanos , Perfusão , Oxigenação por Membrana Extracorpórea/ética , Preservação de Órgãos/métodos , Preservação de Órgãos/ética , Ponte Cardiopulmonar/ética , Obtenção de Tecidos e Órgãos/éticaRESUMO
OBJECTIVE: Specific perioperative risk assessment models have been developed for bariatric, pancreatic, and colorectal surgery. A similar instrument, specific for patients with critical limb ischemia (CLI), could improve patient-centered clinical decision making. We describe a novel tool to predict 30-day major morbidity and mortality (M&M) after bypass surgery for CLI. METHODS: Data for 4985 individuals from the 2007 to 2009 National Surgical Quality Improvement Program were used to develop and internally validate the model. Outcome measures included mortality, major morbidity, and a composite end point (M&M). M&M included mortality and the most severe postoperative morbidities that were highly associated with death (eg, sepsis and major cardiopulmonary complications). More than 30 preoperative factors were tested for association with 30-day mortality, major morbidity, and M&M. Significant predictors in multivariate models were assigned integer values (points), which were added to calculate a patient's Comprehensive Risk Assessment For Bypass (CRAB) score. Performance was assessed (C-index) across all outcome measures and compared with other general tools (American Society of Anesthesiologists class, Surgical Risk Scale) and existing CLI-specific survival prediction models (Finnvasc score, Edifoligide for the Prevention of Infrainguinal Vein Graft Failure [PREVENT III] score) on a distinct validation sample (n = 1620). RESULTS: In the derivation data set (n = 3275), the 30-day mortality rate was 2.9%. The rate of any major morbidity was 19.1%. The composite end point M&M occurred in 10.1%. Significant predictors of M&M by multivariate analysis included age >75 years, prior amputation or revascularization, tissue loss, dialysis dependence, severe cardiac disease, emergency operation, and functional dependence. Applied to a distinct validation sample of 1620 patients, higher CRAB scores were significantly associated with higher rates of mortality, all major morbidities, and M&M (P < .0001). Comparison with other models by assessment of area under the receiver-operating characteristic curve revealed the CRAB was a more accurate predictor of mortality, all major morbidity, and M&M. CONCLUSIONS: The CRAB is a CLI-specific, risk assessment instrument derived from multi-institutional American College of Surgeons-National Surgical Quality Improvement Program surgical outcomes data that out-performs existing prognostic risk indices in the prediction of clinically significant adverse events after bypass surgery. Use of the CRAB as a risk assessment tool provides an evidence basis for patient-centered clinical decision making and may have a role in identifying patients at higher risk for surgical revascularization in whom an endovascular approach is preferable.
Assuntos
Técnicas de Apoio para a Decisão , Isquemia/cirurgia , Veia Safena/transplante , Enxerto Vascular/efeitos adversos , Idoso , Distribuição de Qui-Quadrado , Comorbidade , Estado Terminal , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Modelos Logísticos , Masculino , Análise Multivariada , Seleção de Pacientes , Complicações Pós-Operatórias/mortalidade , Curva ROC , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Enxerto Vascular/mortalidadeAssuntos
Competência Clínica , Ecocardiografia Transesofagiana/ética , Consentimento Livre e Esclarecido/ética , Internato e Residência/ética , Aprendizagem Baseada em Problemas/ética , Competência Clínica/normas , Ecocardiografia Transesofagiana/métodos , Humanos , Consentimento Livre e Esclarecido/normas , Internato e Residência/métodos , Internato e Residência/normas , Aprendizagem Baseada em Problemas/métodosRESUMO
BACKGROUND: Clinicians who prescribe chronic opioid therapy are concerned about identifying patients who are at-risk for misusing, abusing, or diverting (i.e. selling) their pain medications. Experts have specifically recommended using clinical assessment tools as part of a comprehensive plan for mitigating opioid-related risks. These tools are typically short, standardized questionnaires that screen for the presence or absence of putatively aberrant medication-related behaviors thought to be predictive of addiction. Interestingly, these tools remain wholly unregulated by the Food and Drug Administration (FDA) or other authorities. OBJECTIVE: This paper reviews how these instruments are used and the normative assumptions informing their use, fully appreciating that these screening tools do not have the power to diagnose illness or an addiction disorder. CONCLUSION: We conclude that these clinical assessment tools should be regulated because, as we will argue, any screening tool that can assess patients for the potential for opioid-related aberrant behaviors are powerful instruments that merit additional scrutiny and oversight--perhaps by the FDA and other regulatory agencies.
Assuntos
Analgésicos Opioides , Desvio de Medicamentos sob Prescrição/legislação & jurisprudência , Desvio de Medicamentos sob Prescrição/estatística & dados numéricos , Uso Indevido de Medicamentos sob Prescrição/legislação & jurisprudência , Uso Indevido de Medicamentos sob Prescrição/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Humanos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Desvio de Medicamentos sob Prescrição/ética , Inquéritos e Questionários , Estados Unidos , United States Food and Drug AdministrationRESUMO
BACKGROUND: Evidence suggests that some physicians harbor negative attitudes towards patients with substance use disorders (SUDs). The study sought to (1) measure internal medicine residents' attitudes towards patients with SUDs and other conditions; (2) determine whether demographic factors influence regard for patients with SUDs; and (3) assess the efficacy of a 10-hour addiction medicine course for improving attitudes among a subset of residents. METHODS: A prospective cohort study of 128 internal medicine residents at an academic medical center in New York City. Scores from the validated Medical Condition Regard Scale (MCRS) were used to assess attitude towards patients with alcoholism, dependence on narcotic pain medication, heartburn, and pneumonia. Demographic variables included gender, postgraduate training year, and prior addiction education. RESULTS: Mean baseline MCRS scores were lower (less regard) for patients with alcoholism (41.4) and dependence on narcotic pain medication (35.3) than for patients with pneumonia (54.5) and heartburn (48.9) (P < .0001). Scores did not differ based upon gender, prior hours of addiction education, or year of training. After the course, MCRS scores marginally increased for patients with alcoholism (mean increased by 0.16, P = .04 [95% confidence interval, CI: 0.004-0.324]) and dependence on narcotic pain medication (mean increased by 0.09, P = .10 [95% CI: 0.02-0.22]). CONCLUSIONS: Internal medicine residents demonstrate less regard for patients with SUDs. Participation in a course in addiction medicine was associated with modest attitude improvement; however, other efforts may be necessary to ensure that patients with potentially stigmatized conditions receive optimal care.
Assuntos
Atitude do Pessoal de Saúde , Medicina Interna/educação , Internato e Residência , Estereotipagem , Transtornos Relacionados ao Uso de Substâncias/psicologia , Currículo , Educação de Pós-Graduação em Medicina , Feminino , Azia/psicologia , Humanos , Masculino , Pneumonia/psicologia , Estudos ProspectivosRESUMO
Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease requiring maintenance therapy. Traditionally, EoE has been a contraindication to oral immunotherapy (OIT) and a rationale for discontinuing treatment because OIT may induce EoE. Most, but not all patients with OIT-induced EoE experience symptom resolution and histologic remission after discontinuing OIT. Recent studies report OIT continuation even after EoE onset, despite the previously accepted standard of care. This creates clinical as well as ethical challenges for allergists treating these patients. Considering the published literature on EoE and OIT and the primary medical ethics principles of beneficence, nonmaleficence, autonomy, and justice, we discuss the ethical implications of pursuing desensitization despite the potential complications associated with EoE. When ethical principles are in opposition, shared decision-making should be employed to determine whether OIT should be continued after an EoE diagnosis. This article highlights the ethical dilemmas allergists face when determining whether patients with a diagnosis of EoE should continue OIT.
Assuntos
Enterite , Esofagite Eosinofílica , Gastrite , Humanos , Esofagite Eosinofílica/terapia , Esofagite Eosinofílica/etiologia , Gastrite/complicações , Enterite/complicações , Imunoterapia/efeitos adversosRESUMO
OBJECTIVE: To present a clinical ethics case report that illustrates the benefits of using lip-reading interpreters for ventilated patients who are capable of mouthing words. DESIGN: Case report. SETTING: The burn unit of a university teaching hospital in New York City. PATIENT: A 75-yr-old man was admitted to the burn unit with 50% total body surface area burns. He was awake, alert, ventilator-dependent via a tracheostomy, and able to mouth words. INTERVENTIONS: A deaf lip-reading interpreter and a hearing American sign language interpreter worked together in a circuit formation to provide verbal voice for the patient. CONCLUSION: For the ventilated patient who can mouth words, lip-reading interpretation offers an opportunity for communication. It is time we routinely provide lip-reading interpreters as well as recognize the need for prospective studies examining the role of lip-reading in medical settings.
Assuntos
Leitura Labial , Respiração Artificial/psicologia , Idoso , Queimaduras/psicologia , Queimaduras/terapia , Ética Médica , Humanos , MasculinoRESUMO
OBJECTIVE: No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD. DESIGN: A cross-sectional study of PC patients at an urban, academic medical center. SUBJECTS: Two hundred sixty-four English-speaking patients (ages 18-60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits. OUTCOME MEASURES: Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD. RESULTS: Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only "appearing intoxicated or high" documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, "emergency visit for pain," did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6). CONCLUSIONS: EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.
Assuntos
Registros Eletrônicos de Saúde , Uso Indevido de Medicamentos sob Prescrição , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Adolescente , Adulto , Analgésicos Opioides/uso terapêutico , Benzodiazepinas/uso terapêutico , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
Decision making on behalf of an incapacitated patient is challenging, particularly in the context of venoarterial extracorporeal membrane oxygenation (VA-ECMO), a medically complex, high-risk, and costly intervention that provides cardiopulmonary support. In the absence of a surrogate and an advance directive, the clinical team must make decisions for such patients. Because states vary in terms of which decisions clinicians can make, particularly at the end of life, the legal landscape is complicated. This commentary on a case of withdrawal of VA-ECMO in an unrepresented patient discusses Extracorporeal Life Support Organization guidelines for decision making, emphasizing the importance of proportionality in a benefits-to-burdens analysis.
Assuntos
Tomada de Decisões/ética , Serviço Hospitalar de Emergência/ética , Oxigenação por Membrana Extracorpórea/ética , Consentimento do Representante Legal/ética , Consentimento do Representante Legal/legislação & jurisprudência , Suspensão de Tratamento/ética , Adulto , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Masculino , Guias de Prática Clínica como Assunto , Medição de Risco , Taquicardia Ventricular/diagnóstico , Doente TerminalRESUMO
BACKGROUND: Difficult conversations in medical care often occur between physicians and patients' surrogates, individuals entrusted with medical decisions for patients who lack the capacity to make them. Poor communication between patients' surrogates and physicians may exacerbate anxiety and guilt for surrogates, and may contribute to physician stress and burnout. OBJECTIVE: This pilot study assesses the effectiveness of an experiential learning workshop that was conducted in a clinical setting, and aimed at improving resident physician communication skills with a focus on surrogate decision-making. METHODS: From April through June 2016, we assessed internal medicine residents' baseline communication skills through an objective structured clinical examination (OSCE) with actors representing standardized surrogates. After an intensive, 6-hour communication skills workshop, residents were reassessed via an OSCE on the same day. A faculty facilitator and the surrogate evaluated participants' communication skills via the expanded Gap Kalamazoo Consensus Statement Assessment Form. Wilcoxon signed rank tests (α of .05) compared mean pre- and postworkshop scores. RESULTS: Of 44 residents, 33 (75%) participated. Participants' average preworkshop OSCE scores (M = 3.3, SD = 0.9) were significantly lower than postworkshop scores (M = 4.3; SD = 0.8; Z = 4.193; P < .001; effect size r = 0.52). After the workshop, the majority of participants self-reported feeling "more confident." CONCLUSIONS: Residents' communication skills specific to surrogate decision-making benefit from focused interventions. Our pilot assessment of a workshop showed promise, and additionally demonstrated the feasibility of bringing OSCEs and simulated encounters into a busy clinical practice.