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1.
JAMA Netw Open ; 4(8): e2120728, 2021 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-34415317

RESUMO

Importance: Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown. Objective: To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths. Design, Setting, and Participants: A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression. Exposures: A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions. Main Outcomes and Measures: Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability. Results: A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir). Conclusions and Relevance: In this cohort study, EMS transport refusals increased with the COVID-19 outbreak's peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.


Assuntos
COVID-19/epidemiologia , Serviços Médicos de Emergência/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Transporte de Pacientes/estatística & dados numéricos , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Adulto , Idoso , COVID-19/prevenção & controle , Controle de Doenças Transmissíveis/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , SARS-CoV-2
2.
Arch. argent. pediatr ; 119(4): e298-e302, agosto 2021.
Artigo em Inglês, Espanhol | LILACS, BINACIS | ID: biblio-1280998

RESUMO

Con la llegada de las vacunas contra el SARS-CoV-2, un nuevo aspecto a tener en cuenta en la pandemia es el rechazo a la vacunación. Como la recepción de la vacuna, es voluntaria, se plantea cómo abordar la situación de los miembros del equipo de salud que la rechazan. Se exponen argumentos bioéticos de diversas corrientes: el deontologismo kantiano y lo conceptos de universalidad, humanidad y autonomía; el utilitarismo de Mill, con la autoprotección como único fin por el cual la humanidad está habilitada para interferir con la libertad de acción de sus miembros; el principismo de Beauchamp y Childress y los conceptos de beneficencia y autonomía; el principio de oportunidad de Varo Baena; y el principio de solidaridad, derivado de la ética de los derechos humanos. Se incluyen aportes de filósofos contemporáneos como Roberto Espósito, Jean-Luc Nancy y Alberto Giubilini. Se exponen dos contrargumentos: el de no maleficencia y el de contraproducencia. Por último, se plantea que, dado que el bien común (la salud pública, en este caso) es el determinante íntimo y último de la libertad individual e igual para todos, está por encima del beneficio individual


With the development of SARS-CoV-2 vaccines, a new aspect to be taken into consideration in the midst of the pandemic is vaccine refusal. Since vaccination is voluntary, it is necessary to deal with the fact that some health care team members refuse to receive it. Here I put forward different bioethical arguments: Kantian deontology and the principles of universalizability, humanity, and autonomy; Mill's utilitarianism, with self-protection as the sole end for which humankind is authorized to interfere with its members' freedom of action; Beauchamp and Childress' principlism and the concepts of beneficence and autonomy; Varo Baena's principle of opportunity; and the principle of solidarity resulting from the ethics of human rights. The contributions of contemporary philosophers like Roberto Espósito, Jean-Luc Nancy, and Alberto Giubilini are also included. Two counter-arguments are presented: nonmaleficence and counter-production. Lastly, I suggest that, since common good (in this case, public health) is the intimate and final determining factor of individual freedom and is the same for all, it is above any individual benefit.


Assuntos
Humanos , Filosofia Médica , Recusa do Paciente ao Tratamento/ética , Vacinação/ética , Ética Baseada em Princípios , Programas Obrigatórios/ética , Vacinas contra COVID-19 , COVID-19/prevenção & controle , Pessoal de Saúde
3.
Clin Interv Aging ; 16: 1315-1325, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34285476

RESUMO

Purpose: The purpose of this case series is to illustrate the complexity of considerations across health (physical and mental), ethical, human rights and practical domains when an older adult with chronic symptoms of mental illness refuses treatment for a serious medical comorbidity. A broad understanding of these considerations may assist health care professionals in navigating this challenging but common aspect of clinical practice. Case Presentation: Three detailed case reports are described. Participants were older adults with an acute presentation of a chronic mental illness, admitted to a specialized older persons mental health inpatient unit (OPMHU) in an Australian metropolitan hospital. Significant comorbid medical issues were detected or arose during the admission and the patient refused the recommended medical intervention. Data extracted from patients' medical records were analyzed and synthesized into detailed case reports using descriptive techniques. Each patient was assessed as lacking capacity for healthcare and treatment consent and did not have relatives or friends to assist with supported decision-making. Multifaceted aspects of decision-making and management are highlighted. Conclusion: There are multiple complex issues to consider when an older adult with chronic symptoms of mental illness refuses treatment for serious comorbid medical conditions. In addition to optimizing management of the underlying mental illness (which may be impairing capacity to make healthcare decisions), clinicians should adopt a role of advocacy for their patients in considering the potential impact of ageism and stigma on management plans and inequities in physical healthcare. Consultation with specialist medical teams should incorporate multifaceted considerations such as potentially inappropriate treatment and optimum setting of care. Equally important is reflective practice; considering whether treatment decisions may infringe upon human rights or cause trauma.


Assuntos
Pessoal de Saúde/psicologia , Transtornos Mentais/terapia , Relações Profissional-Paciente , Recusa do Paciente ao Tratamento , Idoso , Idoso de 80 Anos ou mais , Austrália , Doença Crônica , Feminino , Direitos Humanos , Humanos , Masculino , Competência Mental
5.
Arch Argent Pediatr ; 119(4): e298-e302, 2021 08.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-34309307

RESUMO

With the development of SARS-CoV-2 vaccines, a new aspect to be taken into consideration in the midst of the pandemic is vaccine refusal. Since vaccination is voluntary, it is necessary to deal with the fact that some health care team members refuse to receive it. Here I put forward different bioethical arguments: Kantian deontology and the principles of universalizability, humanity, and autonomy; Mill's utilitarianism, with selfprotection as the sole end for which humankind is authorized to interfere with its members' freedom of action; Beauchamp and Childress' principlism and the concepts of beneficence and autonomy; Varo Baena's principle of opportunity; and the principle of solidarity resulting from the ethics of human rights. The contributions of contemporary philosophers like Roberto Espósito, Jean-Luc Nancy, and Alberto Giubilini are also included. Two counterarguments are presented: nonmaleficence and counter-production. Lastly, I suggest that, since common good (in this case, public health) is the intimate and final determining factor of individual freedom and is the same for all, it is above any individual benefit.


Assuntos
Vacinas contra COVID-19 , COVID-19/prevenção & controle , Programas Obrigatórios/ética , Filosofia Médica , Ética Baseada em Princípios , Recusa do Paciente ao Tratamento/ética , Vacinação/ética , Humanos
6.
Isr Med Assoc J ; 23(7): 408-411, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34251121

RESUMO

BACKGROUND: Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries. OBJECTIVES: To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic. METHODS: We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications. RESULTS: We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001). CONCLUSIONS: We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition.


Assuntos
Anestesia por Condução , Anestesia Geral , Anestesia Obstétrica , Cesárea , Recusa do Paciente ao Tratamento , Adulto , Anestesia por Condução/métodos , Anestesia por Condução/psicologia , Anestesia por Condução/estatística & dados numéricos , Anestesia Geral/métodos , Anestesia Geral/estatística & dados numéricos , Anestesia Obstétrica/métodos , Anestesia Obstétrica/psicologia , Árabes/psicologia , Árabes/estatística & dados numéricos , COVID-19/epidemiologia , COVID-19/prevenção & controle , Cesárea/métodos , Cesárea/estatística & dados numéricos , Salas de Parto/organização & administração , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Israel/epidemiologia , Inovação Organizacional , Gravidez , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/tendências , Estudos Retrospectivos , Recusa do Paciente ao Tratamento/etnologia , Recusa do Paciente ao Tratamento/estatística & dados numéricos
7.
Transfusion ; 61 Suppl 1: S159-S166, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269430

RESUMO

BACKGROUND: The use of blood products early in the resuscitation of bleeding trauma patients is widely accepted, but made difficult by limited supplies of D- red blood cell (RBC)-containing products. Use of D+ RBC-containing products would alleviate this issue, but could lead to alloimmunization. Risk associated with transfusing D+ RBC in emergency bleeding situations is being reconsidered. The level of concern surrounding emergency transfusion as it relates to future fetal harm was surveyed among surgeons and nurses. METHODS: Faculty and staff in the Departments of Surgery and Nursing were surveyed on the risks of receiving an emergency RBC transfusion and the subsequent potential for fetal harm. Answers were grouped as likely to accept (likely/very likely) or refuse transfusion (unlikely/very unlikely). Participants were compared by sex, and women by child-bearing age, ([15-50 years] vs. [>50 years]). RESULTS: Ninety surveys were initiated with 76 fully completed. Male (n = 39) and female (n = 37) respondents were comparable. Most female respondents (30/37, 81%) were of childbearing age. Overall, both males (38/39, 95%) and females (33/37, 89%; p = .19) were likely to accept a transfusion in an emergency. There was no difference in transfusion acceptance if the risk of fetal harm was presented as 1% (p = .73) or 0.1% (p = .51). Most females (34/37, 92%) were not opposed to transfusion even if there was an unspecified risk of future fetal harm. CONCLUSION: Most of the surgeons and nurses who responded would accept a transfusion in an emergency situation even if it might lead to harming a future fetus.


Assuntos
Transfusão de Eritrócitos/efeitos adversos , Hemorragia/terapia , Reação Transfusional/etiologia , Ferimentos e Lesões/terapia , Adolescente , Adulto , Transfusão de Sangue/métodos , Transfusão de Eritrócitos/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Cooperação do Paciente , Gravidez , Ressuscitação/efeitos adversos , Ressuscitação/métodos , Medição de Risco , Cirurgiões , Inquéritos e Questionários , Centros de Traumatologia , Recusa do Paciente ao Tratamento , Adulto Jovem
8.
Pan Afr Med J ; 38: 291, 2021.
Artigo em Francês | MEDLINE | ID: mdl-34178210

RESUMO

The refusal and abandonment of treatment is a behavior frequently observed in our daily practice. The purpose of this study was to describe the epidemiology and to identify the reasons for refusals and abandonment of treatment. We conducted a prospective study in the emergency surgery at the University Hospital Center of Bouake from 1st January 2018 to 31st December 2018. It involved all patients admitted with traumatic lesions who had refused or abandoned treatment. Data from 106 cases (16%) of refusal and abandonment of treatment out of 662 cases admitted with limb traumas were examined over this period. The average age of patients was 37 years. The study enrolled 77 men (72.6%). Tertiary sector workers accounted for 56.6% (n= 60) of cases. Lesions were dominated by closed fractures (82.1%; n= 87) and pelvic limbs were the most achieved (78.3%; n=83). Treatment was based on surgery (n=85; 80.2% ) and orthopaedic treatment (n=21; 19.8%). The cost of orthopedic treatment was estimated at 26 500 CFA francs (40 euros) while at 250 000 FCFA (380 euros) for surgical treatment. These costs varied as a function of implant prescribed and its location. Refusal of tratment was expressed by patients (n=30; 28.3%) and by parents (n=76; 71.7%). Reported reasons were dominated by financial problems (n=62; 58.5%), trust in traditional medicine (n=42; 39.6%), religious belief (n=2; 1.9%). The average time of refusal was 22 hours. Eighty eight point seven percent (n=94) of patients signed discharge while 11.3% (n=12) escaped. Refusal of care is a recurrent theme in our context and is due to inadequate health care management of people with limited financial resources.


Assuntos
Procedimentos Ortopédicos/estatística & dados numéricos , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Costa do Marfim , Feminino , Fraturas Ósseas/terapia , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto Jovem
9.
Anthropol Med ; 28(2): 156-171, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34169780

RESUMO

Canada's program to examine, transfer and treat Indigenous and Inuit peoples with tuberculosis in Indian Hospitals (ca. 1936 and 1969) has generally been framed by official narratives of population health, benevolence, and care. However, letters written by Inuit patients in Indian hospitals and their kin, and which were addressed to government officials and translated by government employees, challenge this assumption. By focusing on the harmful effects of the segregation and long-term detainment of Inuit peoples away from their communities, the letters theorize TB treatment as multiply harmful and iatrogenic. The letters also showcase how Inuit peoples resisted Indian Hospital treatment and articulated the need for care and treatment to occur within a network of intimate relations, rather than in distant sanatoriums.


Assuntos
Doença Iatrogênica/etnologia , Inuítes , Recusa do Paciente ao Tratamento , Tuberculose , Antropologia Médica , Canadá , História do Século XX , Hospitais de Doenças Crônicas/história , Humanos , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Saúde da População/história , Recusa do Paciente ao Tratamento/etnologia , Recusa do Paciente ao Tratamento/história , Tuberculose/etnologia , Tuberculose/história , Tuberculose/terapia
12.
Lancet Psychiatry ; 8(7): 599-609, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34022972

RESUMO

BACKGROUND: Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having the potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, the views of service users on self-binding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, and human rights. METHODS: This qualitative study used data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision making for patients with bipolar disorder. We included participants who reported that they have been diagnosed with bipolar disorder by a professional (doctor or psychiatrist). In a previous study, quantitative analysis of a closed question about self-binding directives had shown endorsement among a high proportion of participants with bipolar disorder who completed the survey. In this study, we did a thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was done within a multidisciplinary team, including team members with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methods associated with all these areas of expertise were used in the thematic analysis to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues. FINDINGS: Between Oct 23, 2017, and Dec 5, 2017, 932 individuals with a self-reported clinical diagnosis of bipolar disorder completed the internet survey, with 565 individuals (154 men, 400 women, 11 transgender or other), predominantly white British, providing free-text answers to the open question. 463 (82%) of the 565 participants endorsed self-binding directives, of whom 411 (89%) describing a determinate shift to distorted thinking and decision making when unwell as their key justification. Responses indicating ambivalence (37 [7%) of the 565 responses) were dominated by logistical concerns about the drafting and implementation of self-binding directives, whereas those who rejected self-binding directives (65 [12%] of the 565 responses) cited logistical concerns, validity of their thinking when unwell, and potential contravention of human rights. INTERPRETATION: This study is, to our knowledge, the first large study assessing the reasons why mental health service users might endorse or reject the use of self-binding directives. The findings provide empirical support for introducing self-binding directives into mental health services as well as advance decision-making practice and policy, and might help address enduring ethical concerns surrounding possible implementation of the directive while a person retains decision-making capacity. The opinions expressed here in responses given by multiple service users with bipolar disorder challenge a prominent view within international disability rights debates that involuntary treatment and recognition of impaired mental capacity constitute inherent human rights violations. FUNDING: The Wellcome Trust.


Assuntos
Diretivas Antecipadas/psicologia , Transtorno Bipolar/psicologia , Tomada de Decisões , Serviços de Saúde Mental , Recusa do Paciente ao Tratamento , Feminino , Direitos Humanos , Humanos , Masculino , Psiquiatria , Pesquisa Qualitativa , Inquéritos e Questionários , Reino Unido
13.
Bioethics ; 35(6): 596-601, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33890689

RESUMO

Eric C. Ip has recently argued that seriously anorexic service users ought to be assumed to be legally incapacitous to refuse life-saving artificial nutrition unless they can demonstrate otherwise, reversing the ordinary legal presumption in place to protect patients' liberty and values. In this response, I argue against this proposal on two grounds. Firstly, the proposal is wrongfully discriminatory; it would expose service users to serious harm, and wrong them in numerous ways, on the basis of their diagnosis alone, without significantly benefitting them in any way relative to the status quo. Secondly, he is unable to show that a large majority of such service users actually are incapacitous to refuse life-saving artificial nutrition. This means that his proposal would likely involve declaring a large number of actually capacitous patients to be incapacitous, without even the requirement of a formal assessment, and burdening them with the responsibility of proving their clinical team wrong if they wish to avoid deprivation of liberty and/or compelled treatment. Given this, his proposal is indefensible.


Assuntos
Anorexia Nervosa , Anorexia Nervosa/terapia , Humanos , Masculino , Recusa do Paciente ao Tratamento
14.
Ann Emerg Med ; 78(1): 174-190, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33865616

RESUMO

STUDY OBJECTIVE: Studies of early data found that US emergency departments (EDs) were characterized by prolonged patient waiting, long visit times, frequent and prolonged boarding (ie, patients kept waiting in ED hallways or other space outside the ED on admission to the hospital), and patients leaving without receiving or completing treatment. We sought to assess recent trends in ED throughput nationally. METHODS: This was a retrospective cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2006 to 2016. We used survey-weighted generalized linear models to assess changes over time. The primary outcome variables were the number of visits, wait time to consult a physician, length of visit (time from arrival to leaving for home or hospital ward), boarding time, the proportion of patients leaving without being seen, the proportion treated within recommended waiting times, and the proportion dispositioned within 4, 6, and 8 hours. RESULTS: Between 2006 and 2016, the number of ED visits increased from 119.2 million to 145.6 million. During this period, annual median wait time decreased from 31 minutes (interquartile range 14 to 67) to 17 minutes (interquartile range 6 to 45). The proportion of patients who left without being seen declined from 2.0% (95% confidence interval [CI] 1.7% to 2.4%) to 1.1% (95% CI 0.8% to 1.4%). The proportion treated by a qualified practitioner within recommended waiting times increased from 75.5% (95% CI 72.7% to 78.3%) to 80.8% (95% CI 77.2% to 84.4%). Overall, there was no statistically significant change in median length of visit. However, over time, decreased proportions of the sickest patients were discharged within 4, 6, and 8 hours, whereas increased proportions of low-acuity patients were discharged within 4 hours. The distribution of patient boarding time remained fairly unchanged from 2009 to 2015, with a median of approximately 75 minutes. CONCLUSION: Overall, there was improvement in ED timeliness from 2006 to 2016. However, we observed a decrease in the proportion of the sickest patients discharged within 8 hours of arrival, although this may be due to increased ancillary testing or specially consultation over time.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Listas de Espera , Estudos Transversais , Humanos , Estudos Retrospectivos , Inquéritos e Questionários , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Estados Unidos
15.
Pediatr Emerg Med Pract ; 18(5): 1-20, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33885255

RESUMO

Involving patients or their surrogate decision-makers in their care is an important element of modern medical practice. General consent, informed consent, treatment refusal, and shared decision-making are concepts that are used regularly but can be more complex in pediatric emergency settings. This issue summarizes these concepts and provides case examples that may be encountered. It explains the essential elements of informed consent, the distinction between the informed consent process and the document, how to approach treatment refusal, and approaches to involving patients and their surrogates in shared decision-making. Special circumstances include treatment for sexual and mental health conditions, emancipated minors, mature minors, and situations when custody is unclear. Implementation of these concepts can increase patient satisfaction, resolve conflict, and reduce risk.


Assuntos
Tomada de Decisão Compartilhada , Serviço Hospitalar de Emergência , Consentimento Livre e Esclarecido , Recusa do Paciente ao Tratamento , Adolescente , Criança , Pré-Escolar , Tomada de Decisões , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Menores de Idade , Pais , Satisfação do Paciente , Medicina de Emergência Pediátrica/métodos
17.
West J Emerg Med ; 22(2): 148-155, 2021 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-33856294

RESUMO

INTRODUCTION: Emergency department (ED) patients who leave before treatment is complete (LBTC) represent medicolegal risk and lost revenue. We sought to examine LBTC return visits characteristics and potential revenue effects for a large healthcare system. METHODS: This retrospective, multicenter study examined all encounters from January 1-December 31, 2019 at 18 EDs. The LBTC patients were divided into left without being seen (LWBS), defined as leaving prior to completed medical screening exam (MSE), and left subsequent to being seen (LSBS), defined as leaving after MSE was complete but before disposition. We recorded 30-day returns by facility type including median return hours, admission rate, and return to index ED. Expected realization rate and potential charges were calculated for each patient visit. RESULTS: During the study period 626,548 ED visits occurred; 20,158 (3.2%) LBTC index encounters occurred, and 6745 (33.5%) returned within 30 days. The majority (41.7%) returned in <24 hours with 76.1% returning in 10 days and 66.4% returning to index ED. Median return time was 43.3 hours, and 23.2% were admitted. Urban community EDs had the highest 30-day return rate (37.8%, 95% confidence interval, 36.41-39.1). Patients categorized as LSBS had longer median return hours (66.0) and higher admission rates (29.8%) than the LWBS cohort. There was a net potential realization rate of $9.5 million to the healthcare system. CONCLUSION: In our system, LSBS patients had longer return times and higher admission rates than LWBS patients. There was significant potential financial impact for the system. Further studies should examine how healthcare systems can reduce risk and financial impacts of LBTC patients.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Pacientes/psicologia , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Adulto , Comportamento de Escolha , Tratamento de Emergência/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Pacientes Desistentes do Tratamento/psicologia , Satisfação do Paciente , Pacientes/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Triagem/métodos , Listas de Espera
18.
Reprod Health ; 18(1): 79, 2021 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-33858469

RESUMO

BACKGROUND: No Canadian studies to date have examined the experiences of people who decline aspects of care during pregnancy and birth. The current analysis bridges this gap by describing comments from 1123 people in British Columbia (BC) who declined a test or procedure that their care provider recommended. METHODS: In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study, including a cross-sectional survey on experiences of provider-patient interactions over the course of maternity care. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations. RESULTS: More than half of all study participants (n = 2100) declined care at some point during pregnancy, birth, or the postpartum period (53.5%), making this a common phenomenon. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences. CONCLUSIONS: Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.


Assuntos
Atitude do Pessoal de Saúde , Serviços de Saúde Materna , Relações Médico-Paciente , Recusa do Paciente ao Tratamento , Adulto , Colúmbia Britânica , Estudos Transversais , Tomada de Decisão Compartilhada , Feminino , Humanos , Recém-Nascido , Parto , Gravidez
20.
Ann Palliat Med ; 10(4): 4868-4877, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33832317

RESUMO

The literature about the factors associated with cancer treatment refusal, especially by the older patients is scarce. Therefore, this study aimed to identify predictive factors associated with treatment refusal by older patients with cancer. A systematic review was conducted using three databases, Medline, Web of Science, and Scopus with the key concepts, "refusal treatment" and "cancer" and "decision making" and "elderly" or "aged". The search took place in July 2020 and it included articles published in the last 5 years. Of the 211 articles found, 22 were included in the review. Most studies have focused on head and neck and breast cancer treatment decisions and used a quantitative design. The majority of studies evaluated refusal of surgery interventions. Important factors associated with refusal cancer treatment include gender, marital status, race, having government insurance, advanced cancer, poor performance status (cancer stage III or IV) and Charlson Comorbidity Index ≥2. Thus, there are socio-demographic and clinical variables associated with treatment refusal. More studies with the elderly are needed. Understanding these factors may be useful to recognize situations where active education and support can help elderly patients accept optimal care.


Assuntos
Neoplasias da Mama , Recusa do Paciente ao Tratamento , Idoso , Bases de Dados Factuais , Humanos , Estadiamento de Neoplasias
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