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1.
Perspect Biol Med ; 62(3): 383-400, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31495787

RESUMO

The moral pluralism of Western democratic societies results in ethical differences among citizens and health professionals, due to contrasts between the foundational beliefs and values on which their ethical convictions rest. Some of these differences have challenging implications for the practice of medicine when a patient seeks access to a legal medical service that a conscientiously acting physician believes is unethical. Such disagreements raise pivotal questions about competing ethical values, the moral dynamic of shared decision-making, the meaning of conscience, and the extent to which society will accept ethical differences in professional practice. The act of referral is the focal point of this essay, because it appears to be at the front line of some current debates and legal contests about the extent to which society is willing to accommodate conscientious practice by physicians. Some see referrals as a way to balance respect for physician integrity with promotion of patient autonomy; others see referrals as a mistaken attempt at compromise that misunderstands the meaning of moral responsibility and participation. Understanding conscience as integrity helps explain the moral seriousness of conscientious practice and reinforces the need for professional and legal accommodations that respect it.


Assuntos
Consciência , Relações Médico-Paciente , Encaminhamento e Consulta/ética , Democracia , Ética Médica , Acesso aos Serviços de Saúde , Humanos , Princípios Morais , Preferência do Paciente
2.
Infant Ment Health J ; 40(5): 742-756, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31291015

RESUMO

Effecting a paradigm shift from "reproductive health" to "reproductive justice" within the perinatal field requires changes simultaneously at the levels of the individual healthcare provider and the system of care. The Infant-Parent Program at the University of California, San Francisco (UCSF) has extended its pioneering infant and early childhood mental health consultation to perinatal service systems applying an infant mental health approach to programs caring for expecting and new parents. In partnership with two nursing programs, UCSF consultants direct their efforts at supporting reflective practice capacities and use-of-self in patient-provider relationships. Both nursing programs serve vulnerable groups of expectant and new parents who grapple with challenges to health and well-being stemming from structural racism. As reflective capacities are supported within the consultation case conferences, providers spontaneously identify the need for tools to effectively address issues of race, class, and culture and to combat structural racism throughout the healthcare system. Policies and procedures that uphold structural racism cease to be tolerable to providers who bring their full selves to the work that they are trained to do. Using these nurse consultation partnerships as organizational case studies, this article describes a range of challenges that arise for providers and delineates steps to effective engagement toward reproductive justice.


Assuntos
Assistência à Saúde Culturalmente Competente , Pessoal de Saúde , Relações Profissional-Paciente/ética , Racismo/prevenção & controle , Encaminhamento e Consulta , Diversidade Cultural , Assistência à Saúde Culturalmente Competente/métodos , Assistência à Saúde Culturalmente Competente/organização & administração , Feminino , Pessoal de Saúde/psicologia , Pessoal de Saúde/normas , Humanos , Lactente , Saúde do Lactente/etnologia , Saúde Mental/etnologia , Pesquisa em Avaliação de Enfermagem , Gravidez , Encaminhamento e Consulta/ética , Encaminhamento e Consulta/normas , Estados Unidos , Populações Vulneráveis/etnologia
3.
Clin Imaging ; 57: 83-86, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31163294

RESUMO

OBJECTIVE: "Curbside consults" are informal opinions provided by one physician to another. In radiology, it often refers to opinions rendered on imaging performed at outside facilities and has evolved from being a targeted response to a discrete clinical question to a complete over-read in recent years. Given that the consults are usually sought for patients with complex conditions, the potential for error increases with informal reads, often due to the time constraint and lack of adequate information. Misinterpretations and inaccurate documentation by the referring clinician are also more likely. This study assesses the policies and views on curbside consults at academic centers in the United States. MATERIALS AND METHODS: An online survey (via SurveyMonkey.com) was circulated to the 319 active radiologist members of the Association of Program Directors. There were 80 responses, representing a 25% response rate. RESULTS: While most facilities provided second reads (92%), only a few (23%) provided written reports and read the case entirely. The majority (77%) tailored their read to answer specific clinical questions. Approximately two-thirds did not require the outside radiologist's report to be available before their interpretation. Seventy-nine percent were at least mildly concerned about liability. Up to 45% billed for the study; 39% were not aware of the billing practice. CONCLUSION: Curbside consults are widely provided at U.S. academic institutions with only a minority documenting their opinions. The majority are concerned about the legal implications and this paper puts forth recommendations to minimize the potential for errors in patient care and decrease liability.


Assuntos
Padrões de Prática Médica , Radiologia/métodos , Encaminhamento e Consulta , Documentação , Hospitais de Ensino/estatística & dados numéricos , Humanos , Responsabilidade Legal , Encaminhamento e Consulta/ética , Encaminhamento e Consulta/legislação & jurisprudência , Encaminhamento e Consulta/normas , Estados Unidos
6.
Am J Emerg Med ; 37(5): 942-946, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30712948

RESUMO

Emergency Physicians are frequently called upon to treat family members, friends, colleagues, subordinates or others with whom they have a personal relationship; or they may elect to treat themselves. This may occur in the Emergency Department (ED), outside of the ED, as an informal, or "curbside" consultation, long distance by telecommunication or even at home at any hour. In surveys, the vast majority of physicians report that they have provided some level of care to family members, friends, colleagues or themselves, sometime during their professional career. Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician. This article suggests ethical and practical guidance for the emergency physician as to how to approach these situations.


Assuntos
Medicina de Emergência/ética , Família , Encaminhamento e Consulta/ética , Ética Médica , Amigos , Humanos
10.
Gen Hosp Psychiatry ; 55: 15-19, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30199751

RESUMO

OBJECTIVE: Consultation-liaison (C-L) psychiatrists are involved in physician-assisted death (PAD) teams in many permitting jurisdictions. This paper will describe our Canadian PAD experience over 2 years, highlighting the role of C-L psychiatrists, at a large hospital network that provides medical assistance in dying (MAID, as this is called in Canada). METHODS: We will describe the Canadian criteria for MAID, our multispecialty MAID team experience and the roles, issues and concerns experienced by C-L psychiatrists. Some brief patient examples will be provided. RESULTS: Our MAID team has managed 186 MAID inquiries, assessed 95 MAID requests and provided 49 MAID interventions over a 24 month period. The 2 co-leaders of the MAID team, 8 assessors and 1 intervention physician are C-L psychiatrists. Each of the MAID criteria: grievous medical condition, advanced state of irreversible decline, intolerable suffering, natural death reasonably foreseeable, voluntary request, capacity and informed consent pose specific challenges to be resolved in the assessment. Several unique MAID issues, including the role of education and mandatory psychiatric assessment and protocols will also be discussed. CONCLUSIONS: Our experience shows that C-L psychiatrists are well-situated to provide vital expertise and leadership to multispecialty PAD teams.


Assuntos
Atitude do Pessoal de Saúde , Eutanásia , Médicos , Psiquiatria , Suicídio Assistido , Adulto , Canadá , Eutanásia/ética , Eutanásia/legislação & jurisprudência , Humanos , Médicos/ética , Médicos/legislação & jurisprudência , Psiquiatria/ética , Psiquiatria/legislação & jurisprudência , Encaminhamento e Consulta/ética , Encaminhamento e Consulta/legislação & jurisprudência , Suicídio Assistido/ética , Suicídio Assistido/legislação & jurisprudência
11.
Orthopedics ; 41(6): e741-e746, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-30222792

RESUMO

Informed consent is gaining an ever-important place in modern medicine. The practice of patient-centered medicine along with evidence-based medicine requires a balance between the patient's wishes and the physician's oath to do no harm. Surrogate consent, emergency consent, and intraoperative consultation are 3 situations prone to legal and ethical dilemmas in the fulfillment of informed consent. By examining the proposed models and legal precedents that address the challenges in informed consent, discussion of these dilemmas in the context of both law and bioethics may provide a better understanding of how to resolve them. [Orthopedics. 2018; 41(6):e741-e746.].


Assuntos
Emergências , Complicações Intraoperatórias/terapia , Encaminhamento e Consulta/ética , Encaminhamento e Consulta/legislação & jurisprudência , Consentimento do Representante Legal/ética , Consentimento do Representante Legal/legislação & jurisprudência , Temas Bioéticos , Humanos
12.
Pan Afr Med J ; 29: 223, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30100977

RESUMO

Traditionally, minimal potential organ donor referrals emanate from general medicine departments. We use a clinical vignette to draw attention to challenges related to referral of potential organ donors from general internal medicine departments. In addition, we provide potential solutions to overcome challenges and reflect on the ethical issues of non-referral of potential organ donors. It is hoped that this paper will increase the awareness of organ donation in the medical fraternity in Africa and thus mitigate critical shortages of organs for transplantation.


Assuntos
Transplante de Órgãos/ética , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/ética , Adolescente , Humanos , Masculino , Encaminhamento e Consulta/ética , África do Sul , Doadores de Tecidos/ética
15.
J R Soc Med ; 111(7): 240-252, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29672201

RESUMO

Background Practitioners who enhance how they express empathy and create positive expectations of benefit could improve patient outcomes. However, the evidence in this area has not been recently synthesised. Objective To estimate the effects of empathy and expectations interventions for any clinical condition. Design Systematic review and meta-analysis of randomised trials. Data sources Six databases from inception to August 2017. Study selection Randomised trials of empathy or expectations interventions in any clinical setting with patients aged 12 years or older. Review methods Two reviewers independently screened citations, extracted data, assessed risk of bias and graded quality of evidence using GRADE. Random effects model was used for meta-analysis. Results We identified 28 eligible (n = 6017). In seven trials, empathic consultations improved pain, anxiety and satisfaction by a small amount (standardised mean difference -0.18 [95% confidence interval -0.32 to -0.03]). Twenty-two trials tested the effects of positive expectations. Eighteen of these (n = 2014) reported psychological outcomes (mostly pain) and showed a modest benefit (standardised mean difference -0.43 [95% confidence interval -0.65 to -0.21]); 11 (n = 1790) reported physical outcomes (including bronchial function/ length of hospital stay) and showed a small benefit (standardised mean difference -0.18 [95% confidence interval -0.32 to -0.05]). Within 11 trials (n = 2706) assessing harms, there was no evidence of adverse effects (odds ratio 1.04; 95% confidence interval 0.67 to 1.63). The risk of bias was low. The main limitations were difficulties in blinding and high heterogeneity for some comparisons. Conclusions Greater practitioner empathy or communication of positive messages can have small patient benefits for a range of clinical conditions, especially pain. Protocol registration Cochrane Database of Systematic Reviews (protocol) DOI: 10.1002/14651858.CD011934.pub2.


Assuntos
Comunicação , Empatia , Relações Médico-Paciente/ética , Encaminhamento e Consulta/ética , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
16.
J Pediatr ; 199: 79-84.e1, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29631769

RESUMO

OBJECTIVE: To examine how provider report of confidential consultation in the electronic health record is associated with adolescent characteristics, health risk factors, and provider training. STUDY DESIGN: This prospective cohort study was conducted as part of a larger study implementing computerized clinical decision support in 2 urban primary care clinics. Adolescents used tablets to complete screening questions for specified risk factors in the waiting room. Adolescent-reported risk factors included sexual activity, substance use, and depressive symptoms. Providers were prompted on encounter forms to address identified risk factors and indicate whether confidential consultation was provided. Provider types included adolescent medicine board certified pediatrics and general pediatrics. Differences in proportions of adolescents reporting risk factors by provider type were assessed using χ2 tests. Associations between adolescent characteristics, risk factors, and provider-reported confidential consultation were examined using logistic regression analyses. RESULTS: The sample included 1233 English and Spanish-speaking adolescents 12-20 years of age (52% female; 60% black; 50% early adolescent). Patients seen by adolescent medicine board certified providers reported sexual activity, depressive symptoms, and substance use significantly more often than those seen by general pediatric providers. Among patients seen by board certified adolescent medicine providers, confidential consultation was provided to 90%. For those seen by general pediatric providers, confidential consultation was provided to 53%. Results of multiple logistic regression demonstrated that female sex, later adolescence, and clinic location were significantly associated with confidential consultation. CONCLUSIONS: Provider training is needed to reinforce the importance of confidential consultation for all adolescents.


Assuntos
Serviços de Saúde do Adolescente/organização & administração , Medicina do Adolescente/métodos , Confidencialidade , Relações Médico-Paciente/ética , Atenção Primária à Saúde/ética , Encaminhamento e Consulta/ética , Inquéritos e Questionários , Adolescente , Criança , Feminino , Seguimentos , Humanos , Masculino , Estudos Prospectivos , Fatores de Risco , Adulto Jovem
17.
Gerontology ; 64(3): 222-228, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29428953

RESUMO

"Overtreatment" is a neologism coined some 15 years ago to denote medical and surgical interventions that are unnecessary. It is a topical term for an old concept. However, it has rapidly become a shibboleth for those inclined toward finger-pointing and blaming in matters of health policy. As such, it is a "foe" that heats up rather than modulates debate. But if one examines the notion in the context of the contemporary patient-physician dialogue, it is anything but a foe. Overtreatment and its fellow travelers, overutilization and overprescription, face off with contrary notions when a patient contends with the challenge of evaluating any clinical option.


Assuntos
Sobremedicalização , Idoso , Tomada de Decisão Clínica/ética , Medicina Baseada em Evidências/ética , Geriatria/ética , Geriatria/tendências , Humanos , Sobremedicalização/prevenção & controle , Metanálise como Assunto , Relações Médico-Paciente/ética , Encaminhamento e Consulta/ética
18.
J Med Ethics ; 44(3): 167-170, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-27343284

RESUMO

Discrimination and inequalities in healthcare can be experienced by many patients due to many characteristics ranging from the obviously visible to the more subtly noticeable, such as race and ethnicity, legal status, social class, linguistic fluency, health literacy, age, gender and weight. Discrimination can take a number of forms including overt racist statement, stereotyping or explicit and implicit attitudes and biases. This paper presents the case study of a complex transcultural clinical encounter between the mother of a young infant in a highly vulnerable social situation and a hospital healthcare team. In this clinical setting, both parties experienced difficulties, generating explicit and implicit negative attitudes that heightened into reciprocal mistrust, conflict and distress. The different factors influencing their conscious and unconscious biases will be analysed and discussed to offer understanding of the complicated nature of human interactions when faced with vulnerability in clinical practice. This case vignette also illustrates how, even in institutions with long-standing experience and many internal resources to address diversity and vulnerability, cultural competence remains a constant challenge.


Assuntos
Disparidades em Assistência à Saúde/ética , Pessoas em Situação de Rua , Mães/psicologia , Relações Médico-Paciente/ética , Encaminhamento e Consulta/ética , Imigrantes Indocumentados , Adulto , Atitude do Pessoal de Saúde/etnologia , Competência Cultural , Feminino , Alfabetização em Saúde , Disparidades em Assistência à Saúde/etnologia , Pessoas em Situação de Rua/psicologia , Humanos , Lactente , Masculino , Preconceito , Apoio Social , Imigrantes Indocumentados/psicologia
19.
Natl Med J India ; 31(4): 215-218, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-31134926

RESUMO

Telemedicine was considered futuristic and experimental some years ago, but it is a reality today. It is now emerging as an important tool for convenient as well as specialized healthcare, particularly for patients in remote locations with limited access to standardized healthcare services. However, there are multiple challenges to realizing its full potential. We focus on some key medicolegal and ethical issues such as doctor-patient relationship, informed consent, rights of the patient, malpractice, and principles of confidentiality relevant to the practice of telemedicine and virtual consultation. We explore the global as well as the Indian legal perspective pertaining to the application of telemedicine. The absence of specific laws for registration and practice of telemedicine and virtual consul-tation in India acts as a deterrent for medical practitioners to engage in its potential use. Hence, there is a need for specific legislation.


Assuntos
Confidencialidade/legislação & jurisprudência , Consentimento Livre e Esclarecido/legislação & jurisprudência , Relações Médico-Paciente/ética , Encaminhamento e Consulta/legislação & jurisprudência , Telemedicina/legislação & jurisprudência , Confidencialidade/ética , Humanos , Índia , Consentimento Livre e Esclarecido/ética , Imperícia/legislação & jurisprudência , Encaminhamento e Consulta/ética , Telemedicina/ética , Telemedicina/métodos
20.
Healthc Q ; 20(2): 23-26, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28837010

RESUMO

Requests for a second medical opinion (SMO) by patients or substitute decision-makers (SDMs) can arise during end-of-life disputes in critical care. Such disagreements between patients or SDMs and physicians often pertain to specific elements of the decision-making process related to withholding or withdrawing of life-sustaining treatments. When these disputes occur in the critical care setting in Canada, practicalities and policy barriers prevent an SDM from obtaining an SMO without support from healthcare providers; moreover, in a majority of these cases the SDM will require the facilitation of a physician who is often the same individual with whom they are in conflict. Institutional and a national society's policy statements propose SMOs as an important component of a conflict resolution process for end-of-life disputes (Bosslet et al. 2015; Singer et al. 2001). However, these policies do not provide specific guidance to physicians on how to fairly consider SMO requests. Given the vulnerable position of patients and their SDMs in the critical care context and in order to promote fairness, physicians should apply consistent standards in deciding whether to facilitate a request for an SMO. To guide physicians' decision-making and inform future policy development, we propose three ethical principles for considering SDM requests for an SMO in critical care at the end of life.


Assuntos
Cuidados Críticos/ética , Dissidências e Disputas , Encaminhamento e Consulta/ética , Canadá , Tomada de Decisões/ética , Humanos , Médicos/ética , Assistência Terminal/ética
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