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J Clin Ethics ; 30(4): 331-337, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31851624


Situations in which patients lack medical decision-making (MDM) capacity raise ethical challenges, especially when the patients decline care that their surrogate decision makers and/or clinicians agree is indicated. These patients are a vulnerable population and should receive treatment that is the standard of care, in line with their the values of their authentic self, just as any other patient would. But forcing treatment on patients who refuse it, even though they lack capacity, carries medical and psychological risks to the patients and the hospital staff. It is also often impractical to force some treatments, especially in the long term. For example, independent of the ethical "should" question, how would one force hemodialysis for the rest of a patient's life, or force a surgery that requires weeks of post-operative physical therapy? In this article we present a novel algorithm that can help clinicians with ethical and practical decision making, with the goals of achieving the best outcomes for patients and reducing moral distress for their caretakers and clinicians.

Tomada de Decisão Clínica/ética , Tomada de Decisões , Ética Clínica , Recusa do Paciente ao Tratamento , Humanos , Competência Mental , Participação do Paciente , Diálise Renal , Recusa do Paciente ao Tratamento/ética
BMC Health Serv Res ; 17(1): 273, 2017 04 14.
Artigo em Inglês | MEDLINE | ID: mdl-28410614


BACKGROUND: Patients with frequent hospital readmissions, or high-utilizer patients (HUPs), are a major driver of rising healthcare costs in the United States. This group has a significant burden of medical illness, but less is known about whether or how social determinants of health may drive their increased healthcare use and poor health outcomes. Our study aimed to define the population of HUPs at a large, safety-net hospital system, to understand how these patients differ from patients who are not HUPs, and to analyze how their demographic, medical, and social factors contribute to their healthcare use and mortality rates. METHODS: For this case-control study, data were collected via retrospective chart review. We included 247 patients admitted three or more times in a single calendar year between 2011 and 2013 and 247 controls with one or two admissions in a single calendar year matched for age, sex, and year of high-utilization. We used multivariable logistic regression models to understand which demographic, clinical, and social factors were associated with HUP status, and if HUP status was independently associated with mortality. RESULTS: The factors that contributed significant odds of being a HUP included having Medicaid (OR 3.34, 95% CI 1.50, 7.44) or Medicare (OR 3.39, 95% CI 1.50, 7.67), having a history of recreational drug use (OR 2.44, 95% 1.36, 4.38), and being homeless (OR 3.73, 95% CI 1.69, 8.23) The mortality rate among HUPs was 22.6% compared to 8.9% among controls (p < 0.0001). CONCLUSIONS: These data show that social factors are related to high-utilization in this population. Future efforts to understand and improve the health of this population need to incorporate non-clinical patient factors.

Doença Crônica/epidemiologia , Assistência à Saúde/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Idoso , Estudos de Casos e Controles , Doença Crônica/economia , Doença Crônica/mortalidade , Demografia , Feminino , Hospitalização/economia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Estudos Retrospectivos , Estados Unidos/epidemiologia , População Urbana
AMA J Ethics ; 19(4): 349-356, 2017 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-28430568


One way practitioners learn ethics is by reflecting on experience. They may reflect in the moment (reflection-in-action) or afterwards (reflection-on-action). We illustrate how a teaching clinician may transform relationships with patients and teach person-centered care through reflective learning. We discuss reflective learning pedagogies and present two case examples of our preferred method, guided group reflection using narratives. This method fosters moral development alongside professional identity formation in students and advanced learners. Our method for reflective learning addresses and enables processing of the most pressing ethical issues that learners encounter in practice.

Ética Clínica/educação , Narração , Aprendizagem Baseada em Problemas , Ensino , Atitude do Pessoal de Saúde , Competência Clínica , Humanos , Princípios Morais
MedEdPORTAL ; 13: 10647, 2017 10 26.
Artigo em Inglês | MEDLINE | ID: mdl-30800848


Introduction: Half of the U.S. population has chronic illness. Many disparities exist in health care for management of chronic disease among poorer individuals, including decreased access to healthy foods, homelessness, and difficulty navigating large hospital systems due to low health literacy. A survey of resident physicians found significant gaps in preparedness to provide cross-cultural care. Education is needed to promote consideration of patients' social and cultural barriers in managing disease and navigating the health care system. This module was created as an introduction to social determinants of health, and highlights disparities in access to healthy food, water, shelter, and medical care in a sample of the residents' own continuity clinic patient panel. Methods: We designed this experiential module to help internal medicine residents at an urban institution better understand how social constructs might hinder patient health. Activities were chosen by learners from a list of options, and carried out in small groups during a half day of protected time. We used reflective writing exercises to elicit resident thoughts about the module. Results: Thirty-nine second-year residents participated in the module. Following the course, 41% of residents submitted reflective statements about their experience. Reflective responses suggest an enhanced appreciation for social determinants of health, a sense of empowerment to advocate for better patient resources, and an appreciation for systems-level factors that play a role in social determinants of health. Discussion: Our results demonstrate that a short, experience-based module can impact resident attitudes about social determinants and improve advocacy around identifying community resources.

Determinantes Sociais da Saúde/tendências , Estudantes de Medicina/psicologia , Atitude do Pessoal de Saúde , Educação de Pós-Graduação em Medicina/métodos , Humanos , Internato e Residência/métodos , Percepção , Provedores de Redes de Segurança/organização & administração , Provedores de Redes de Segurança/estatística & dados numéricos , Estudantes de Medicina/estatística & dados numéricos
Am J Hosp Palliat Care ; 32(8): 829-34, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25216735


Increasingly clinicians are using palliative care to address the symptomatic and psychosocial effects of disease often missed by routine clinical care, termed "early" palliative care. Within an inner-city medical center, we began a program to integrate early palliative care into HIV inpatient care. Patient symptom burden and desired services were assessed and compared to provider perceptions of patient's needs. From 2010-2012, 10 patients, with a median CD4+ T-cell count of 32.5 cells/µL, and 34 providers completed the survey. Providers ranked their patients' fatigue, sadness, anxiety, sexual dysfunction, and body image significantly higher than patients it for themselves. Patients ranked medical care, pharmacy, social work, physical therapy, and housing as significantly more important to them than providers estimated them to be. These differences may reflect the fact that physicians often overlook patients' unmet basic needs. Early palliative care may narrow this gap between providers' and patients' perceptions of needs through good communication and targeting barriers, such as housing instability, which are vital to overcome for consistent long-term follow up.

Infecções por HIV/terapia , Cuidados Paliativos/métodos , Adulto , Feminino , Humanos , Masculino , Determinação de Necessidades de Cuidados de Saúde , Inquéritos e Questionários
J Gen Intern Med ; 29(10): 1392-9, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24664441


BACKGROUND: Accountable care organizations (ACOs) are proliferating as a solution to the cost crisis in American health care, and already involve as many as 31 million patients. ACOs hold clinicians, group practices, and in many circumstances hospitals financially accountable for reducing expenditures and improving their patients' health outcomes. The structure of health care affects the ethical issues arising in the practice of medicine; therefore, like all health care organizational structures, ACOs will experience ethical challenges. No framework exists to assist key ACO stakeholders in identifying or managing these challenges. METHODS: We conducted a structured review of the medical ACO literature using qualitative content analysis to inform identification of ethical challenges for ACOs. RESULTS: Our analysis found infrequent discussion of ethics as an explicit concern for ACOs. Nonetheless, we identified nine critical ethical challenges, often described in other terms, for ACO stakeholders. Leaders could face challenges regarding fair resource allocation (e.g., about fairly using ACOs' shared savings), protection of professionals' ethical obligations (especially related to the design of financial incentives), and development of fair decision processes (e.g., ensuring that beneficiary representatives on the ACO board truly represent the ACO's patients). Clinicians could perceive threats to their professional autonomy (e.g., through cost control measures), a sense of dual or conflicted responsibility to their patients and the ACO, or competition with other clinicians. For patients, critical ethical challenges will include protecting their autonomy, ensuring privacy and confidentiality, and effectively engaging them with the ACO. DISCUSSION: ACOs are not inherently more or less "ethical" than other health care payment models, such as fee-for-service or pure capitation. ACOs' nascent development and flexibility in design, however, present a time-sensitive opportunity to ensure their ethical operation, promote their success, and refine their design and implementation by identifying, managing, and conducting research into the ethical issues they might face.

Organizações de Assistência Responsáveis/ética , Alocação de Recursos/ética , Organizações de Assistência Responsáveis/economia , Humanos , Equipe de Assistência ao Paciente/economia , Equipe de Assistência ao Paciente/ética , Participação do Paciente/economia , Alocação de Recursos/economia