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Tarzian AJ. Trauma-Informed Ethics Consultation in the ICU: Exploring Best Practices in a Case Involving a Self-Inflicted Gunshot Wound. Am J Bioeth 2023; 23:96-97. [PMID: 36594994 DOI: 10.1080/15265161.2023.2146409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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Tarzian AJ, Berkowitz KA, Geppert CM. Tertiary Healthcare Ethics Consultation: Enhancing Access to Expertise. The Journal of Clinical Ethics 2022. [DOI: 10.1086/jce2022334314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Tarzian AJ. Who's Abandoning Whom? The Role of Ethics Consultation for Unaccompanied Emergency Department Patients with Dementia. Am J Bioeth 2022; 22:84-85. [PMID: 35737479 DOI: 10.1080/15265161.2022.2076406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Abstract
A 1999-2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to "best informants" in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC.
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Affiliation(s)
- Ellen Fox
- Altarum Institute
- Fox Ethics Consulting
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Abstract
To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners' opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive perceptions of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted.
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Affiliation(s)
- Ellen Fox
- Altarum Institute
- Fox Ethics Consulting
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Geppert CM, Berkowitz KA, Schonfeld T, Tarzian AJ. COVID-19 Ethics Debrief: Pearls and Pitfalls of a Hub and Spoke Model. The Journal of Clinical Ethics 2022. [DOI: 10.1086/jce2022331063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Tarzian AJ. Whose Neglect? Exploring Patient and Caregiver Boundaries in Advanced Dementia. Am J Bioeth 2022; 22:71-72. [PMID: 34962193 DOI: 10.1080/15265161.2022.2002016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Geppert CM, Berkowitz KA, Schonfeld T, Tarzian AJ. COVID-19 Ethics Debrief: Pearls and Pitfalls of a Hub and Spoke Model. J Clin Ethics 2022; 33:63-68. [PMID: 35302521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
A hub and spoke model offers an effective and efficient approach to providing informed guidance to those who need it. The National Center for Ethics in Health Care (NCEHC) at the Veterans Health Administration, Department of Veterans Affairs, is the largest known hub and spoke healthcare ethics delivery model. In this article, we describe ways NCEHC's hub and spoke configuration succeeded during the COVID-19 pandemic, as well as limitations of the model and possible improvements to inform adoption at other healthcare systems.
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Affiliation(s)
- Cynthia Ma Geppert
- Health Care Ethicist and Director of Ethics Education, VHA National Center for Ethics in Health Care, U.S. Department of Veterans Affairs, Washington, District of Columbia USA.
| | - Kenneth A Berkowitz
- Senior Ethicist, VHA National Center for Ethics in Health Care, and Co-Chair of the EHRM Ethics Council, Associate Professor of Medicine and Population Health (Ethics), New York University School of Medicine, New York, New York USA.
| | - Toby Schonfeld
- Executive Director, VHA National Center for Ethics in Health Care, Washington, District of Columbia USA.
| | - Anita J Tarzian
- Deputy Executive Director, VHA National Center for Ethics in Health Care, Wasington, District of Columbia USA.
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Abstract
BACKGROUND While previous research has examined various aspects of ethics consultation (EC) in U.S. hospitals, certain EC practices have never been systematically studied. METHODS To address this gap, we surveyed a random stratified sample of 600 hospitals about aspects of EC that had not been previously explored. RESULTS New findings include: in 26.0% of hospitals, the EC service performs EC for more than one hospital; 72.4% of hospitals performed at least one non-case consultation; in 56% of hospitals, ECs are never requested by patients or families; 59.0% of case consultations involve conflict; the usual practice is to visit the patient in all formal EC cases in 32.5% of hospitals; 56.6% of hospitals do not include a formal meeting in most EC cases; 61.1% of hospitals do not routinely assess ethics consultants' competencies; and 31.6% of hospitals belong to a bioethics network. We estimate the total number of non-case consultations performed in U.S. hospitals to be approximately one half the number of case consultations; we estimate the total number of ECs performed in U.S. hospitals, including both case and non-case consultations, to be just over 100,000 per year. CONCLUSIONS These findings expand our current understanding of EC in U.S. hospitals, and raise several concerns that suggest a need for further research.
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Affiliation(s)
- Ellen Fox
- Altarum Institute, Washington, DC, USA.,Fox Ethics Consulting, Arlington, Virginia, USA
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland, USA
| | - Anita J Tarzian
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, USA.,University of Maryland, Baltimore, Maryland, USA
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Fox E, Tarzian AJ, Danis M, Duke CC. Ethics Consultation in United States Hospitals: Assessment of Training Needs. The Journal of Clinical Ethics 2021. [DOI: 10.1086/jce2021323247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Elson N, Gwon H, Hoffmann DE, Kelmenson AM, Khan A, Kraus JF, Onyegwara CC, Povar G, Sheikh F, Tarzian AJ. Getting Real: The Maryland Healthcare Ethics Committee Network's COVID-19 Working Group Debriefs Lessons Learned. HEC Forum 2021; 33:91-107. [PMID: 33582886 PMCID: PMC7882050 DOI: 10.1007/s10730-021-09442-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Abstract
Responding to a major pandemic and planning for allocation of scarce resources (ASR) under crisis standards of care requires coordination and cooperation across federal, state and local governments in tandem with the larger societal infrastructure. Maryland remains one of the few states with no state-endorsed ASR plan, despite having a plan published in 2017 that was informed by public forums across the state. In this article, we review strengths and weaknesses of Maryland's response to COVID-19 and the role of the Maryland Healthcare Ethics Committee Network (MHECN) in bridging gaps in the state's response to prepare health care facilities for potential implementation of ASR plans. Identified "lessons learned" include: Deliberative Democracy Provided a Strong Foundation for Maryland's ASR Framework; Community Consensus is Informative, Not Normative; Hearing Community Voices Has Inherent Value; Lack of Transparency & Political Leadership Gaps Generate a Fragmented Response; Pandemic Politics Requires Diplomacy & Persistence; Strong Leadership is Needed to Avoid Implementing ASR … And to Plan for ASR; An Effective Pandemic Response Requires Coordination and Information-Sharing Beyond the Acute Care Hospital; and The Ability to Correct Course is Crucial: Reconsidering No-visitor Policies.
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Affiliation(s)
| | - Howard Gwon
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Adam M Kelmenson
- Faculty of Medicine, Department of Bioethics, The Chinese University of Hong Kong, Shatin, New Territories, HKSAR, China
| | - Ahmed Khan
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Joanne F Kraus
- Johns Hopkins University School of Medicine (Retired), Baltimore, MD, USA
| | | | - Gail Povar
- GWU School of Medicine and Health Sciences, Washington, DC, USA
| | - Fatima Sheikh
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Anita J Tarzian
- Maryland Healthcare Ethics Committee Network, University of Maryland Carey School of Law, Baltimore, MD, USA.
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Tarzian AJ, Geppert CMA. The Veterans Health Administration Approach to COVID-19 Vaccine Allocation-Balancing Utility and Equity. Fed Pract 2021; 38:52-54. [PMID: 33716479 DOI: 10.12788/fp.0093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Anita J Tarzian
- is Deputy Executive Director of the US Department Veterans Affairs National Center for Ethics in Health Care. is Editor-in-Chief; Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System; and Professor and Director of Ethics Education at the University of New Mexico School of Medicine in Albuquerque
| | - Cynthia M A Geppert
- is Deputy Executive Director of the US Department Veterans Affairs National Center for Ethics in Health Care. is Editor-in-Chief; Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System; and Professor and Director of Ethics Education at the University of New Mexico School of Medicine in Albuquerque
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Fox E, Tarzian AJ, Danis M, Duke CC. Ethics Consultation in United States Hospitals: Assessment of Training Needs. J Clin Ethics 2021; 32:247-255. [PMID: 34339396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND To help inform the development of more accessible, acceptable, and effective ethics consultation (EC) training programs, we conducted an EC training needs assessment, exploring ethics practitioners' opinions on: the relative importance of various EC practitioner competencies; the potential market for EC training (that is, how many individuals would benefit and how much individuals and hospitals would be willing to pay); and the preferred content, format, and characteristics of EC training. METHODS As part of a multipart study, we surveyed "best informants" who self-identified as the person most actively involved in EC or healthcare ethics in a random sample of 600 U.S. general hospitals, stratified for bed size. RESULTS The competency that was ranked most important for a lead or solo ethics consultant was knowledge of ethics, while common sense was ranked least important. The median estimated number of individuals at each hospital who would benefit from EC training was six at the basic level, three at the advanced level, and two for EC management training. In 19.1 percent of hospitals, respondents thought their hospital would not be willing to pay anything for EC training within the next two years. Respondents thought potential trainees would be likely to participate in EC training on multiple different topics. Opinions varied widely on preferred formats. Most respondents thought it very important to be able to interact with instructors and with other trainees, practice EC skills, receive a certificate for completing EC training, and complete EC training during work hours. CONCLUSIONS These findings provide U.S. population data that may be useful to healthcare educators and bioethics leaders in their efforts to develop EC training programs and products that match trainees' preferences and needs.
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Affiliation(s)
- Ellen Fox
- Fox Ethics Consulting, Arlington, Virginia USA
| | - Anita J Tarzian
- National Center for Ethics in Health Care, Veterans Health Administration, District of Columbia USA
| | - Marian Danis
- Section on Ethics and Health Policy, Department of Bioethics, National Institutes of Health, Bethesda, Maryland USA
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Pope TM, Bennett J, Carson SS, Cederquist L, Cohen AB, DeMartino ES, Godfrey DM, Goodman-Crews P, Kapp MB, Lo B, Magnus DC, Reinke LF, Shirley JL, Siegel MD, Stapleton RD, Sudore RL, Tarzian AJ, Thornton JD, Wicclair MR, Widera EW, White DB. Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement. Am J Respir Crit Care Med 2020; 201:1182-1192. [PMID: 32412853 PMCID: PMC7233335 DOI: 10.1164/rccm.202003-0512st] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as “unrepresented.” There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice. Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting. Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law. Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient’s preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight. Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.
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Gwon H, Haeri M, Hoffmann DE, Khan A, Kelmenson A, Kraus JF, Onyegwara C, Paradissis C, Povar G, Schwartz J, Sheikh F, Tarzian AJ. Maryland's Experience With the COVID-19 Surge: What Worked, What Didn't, What Next? Am J Bioeth 2020; 20:150-152. [PMID: 32716787 DOI: 10.1080/15265161.2020.1779404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- H Gwon
- Johns Hopkins University Bloomberg School of Public Health
| | - M Haeri
- University of Maryland Medical Center
| | | | - A Khan
- University of Maryland Medical Center
| | | | | | | | | | - G Povar
- George Washington University Hospital
| | - J Schwartz
- University of Maryland Carey School of Law
| | - F Sheikh
- Johns Hopkins School of Medicine
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Abstract
The success of fecal microbiota transplantation (FMT) as a treatment for Clostrioides difficile infection (CDI) has stirred excitement about the potential for microbiota transplantation as a therapy for a wide range of diseases and conditions. In this article, we discuss vaginal microbiota transplantation (VMT) as "the next frontier" in microbiota transplantation and identify the medical, regulatory, and ethical challenges related to this nascent field. We further discuss what we anticipate will be the first context for testing VMT in clinical trials, prevention of the recurrence of a condition referred to as bacterial vaginosis (BV). We also compare clinical aspects of VMT with FMT and comment on how VMT may be similar to or different from FMT in ways that may affect research design and regulatory decisions.
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Affiliation(s)
- Kevin DeLong
- Kevin DeLong, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Fareeha Zulfiqar, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Diane E. Hoffmann, J.D., is at the University of Maryland Francis King Carey School of Law. Anita J. Tarzian, Ph.D., R.N., is at the University of Maryland Francis King Carey School of Law and the School of Nursing. Laura M. Ensign, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Departments of Gynecology and Obstetrics, Infectious Diseases, Pharmacology and Molecular Sciences, and Oncology, Johns Hopkins University School of Medicine, and the Departments of Chemical & Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University
| | - Fareeha Zulfiqar
- Kevin DeLong, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Fareeha Zulfiqar, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Diane E. Hoffmann, J.D., is at the University of Maryland Francis King Carey School of Law. Anita J. Tarzian, Ph.D., R.N., is at the University of Maryland Francis King Carey School of Law and the School of Nursing. Laura M. Ensign, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Departments of Gynecology and Obstetrics, Infectious Diseases, Pharmacology and Molecular Sciences, and Oncology, Johns Hopkins University School of Medicine, and the Departments of Chemical & Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University
| | - Diane E Hoffmann
- Kevin DeLong, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Fareeha Zulfiqar, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Diane E. Hoffmann, J.D., is at the University of Maryland Francis King Carey School of Law. Anita J. Tarzian, Ph.D., R.N., is at the University of Maryland Francis King Carey School of Law and the School of Nursing. Laura M. Ensign, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Departments of Gynecology and Obstetrics, Infectious Diseases, Pharmacology and Molecular Sciences, and Oncology, Johns Hopkins University School of Medicine, and the Departments of Chemical & Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University
| | - Anita J Tarzian
- Kevin DeLong, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Fareeha Zulfiqar, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Diane E. Hoffmann, J.D., is at the University of Maryland Francis King Carey School of Law. Anita J. Tarzian, Ph.D., R.N., is at the University of Maryland Francis King Carey School of Law and the School of Nursing. Laura M. Ensign, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Departments of Gynecology and Obstetrics, Infectious Diseases, Pharmacology and Molecular Sciences, and Oncology, Johns Hopkins University School of Medicine, and the Departments of Chemical & Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University
| | - Laura M Ensign
- Kevin DeLong, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Fareeha Zulfiqar, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Diane E. Hoffmann, J.D., is at the University of Maryland Francis King Carey School of Law. Anita J. Tarzian, Ph.D., R.N., is at the University of Maryland Francis King Carey School of Law and the School of Nursing. Laura M. Ensign, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Departments of Gynecology and Obstetrics, Infectious Diseases, Pharmacology and Molecular Sciences, and Oncology, Johns Hopkins University School of Medicine, and the Departments of Chemical & Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University
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Tarzian AJ. Is There a Duty to Warn Parents of a Cancer-Causing Genetic Mutation? Am J Bioeth 2018; 18:73-74. [PMID: 30040567 DOI: 10.1080/15265161.2018.1478502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Hageman SA, Tarzian AJ, Cagle J. Challenges of Dealing with Financial Concerns during Life-Threatening Illness: Perspectives of Health Care Practitioners. J Soc Work End Life Palliat Care 2018; 14:28-43. [PMID: 29505397 DOI: 10.1080/15524256.2018.1432008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The costs of serious medical illness and end of life care are often a heavy burden for patients and families (Collins, Stepanczuk, Williams, & Rich, 2016 ; Kim, 2007 ; May et al., 2014 ; Zarit, 2004 ). Twenty-six practitioners, including social workers, managers/administrators, supervisors, and case managers from five health care settings, participated in qualitative semistructured interviews about financial challenges patients encountered. Seven practitioners took part in a focus group. Practitioners were recruited from hospice (n = 5), long-term care (n = 5), intensive care (n = 5), dialysis (n = 6), and oncology (n = 5). Interview and focus group questions focused on financial challenges patients encountered when facing life-threatening illness. Interview data were transcribed and thematically coded and trustworthiness of data was established with peer debriefing, member checking, and agreement on themes among the authors. Practitioners described interacting micro, meso, and macroinfluences on the financial well-being and challenges patients encountered. Microlevel influences involved patient characteristics, such as their demographic profile and/or health status that set them up for financial aptitude or challenges. Macrolevel influences involved the larger health care/safety net system, which provided valuable resources for some patients but not others. Practitioners also discussed the mesolevel of influence, the local setting where they worked to match available resources with patients' individual needs given the constraints emerging from the micro and macrolevels. Practitioners described how they navigated the interplay of these three areas to meet patients' needs and cope with financial challenges. Implications for practice point to directly addressing the kind of financial concerns that patients and families facing financial burden from serious medical illness have, and identifying ways to bridge knowledge and resource access gaps at the individual, organizational, and societal levels.
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Affiliation(s)
- Sally A Hageman
- a University of Maryland, Baltimore, School of Social Work , Baltimore , Maryland , USA
| | - Anita J Tarzian
- b University of Maryland, Baltimore, School of Nursing , Baltimore , Maryland , USA
| | - John Cagle
- a University of Maryland, Baltimore, School of Social Work , Baltimore , Maryland , USA
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Tarzian AJ, Cheevers NB. Maryland's Medical Orders for Life-Sustaining Treatment Form Use: Reports of a Statewide Survey. J Palliat Med 2017; 20:939-945. [DOI: 10.1089/jpm.2016.0440] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anita J. Tarzian
- Department of Family and Community Health, University of Maryland School of Nursing, Baltimore, Maryland
- Maryland Healthcare Ethics Committee Network, University of Maryland Francis King Carey School of Law, Baltimore, Maryland
| | - Nadia B. Cheevers
- Law and Health Care Program, University of Maryland Francis King Carey School of Law, Baltimore, Maryland
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Tarzian AJ. Withdrawing Life Support in Pregnancy: State Laws and Implications for Ethics. Am J Bioeth 2017; 17:75-76. [PMID: 28661735 DOI: 10.1080/15265161.2017.1314708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Tarzian AJ, Spike JP. Preemptive C-Section Refusal Based on Religious Beliefs. Am J Bioeth 2017; 17:92-93. [PMID: 27996922 DOI: 10.1080/15265161.2016.1251774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Spike JP, Tarzian AJ. Comfort Care Request for Preterm Infant. Am J Bioeth 2017; 17:82-83. [PMID: 27996926 DOI: 10.1080/15265161.2016.1251772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Spike J, Tarzian AJ. Alone and Saying No. Am J Bioeth 2016; 16:76-77. [PMID: 26832107 DOI: 10.1080/15265161.2015.1132050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Spike J, Tarzian AJ. Parental Neglect or Appropriate End-of-Life Care? Am J Bioeth 2016; 16:68-69. [PMID: 26832103 DOI: 10.1080/15265161.2015.1132038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Abstract
For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here.
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Affiliation(s)
- Anita J Tarzian
- a University of Maryland School of Nursing and Francis King Carey School of Law
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Tarzian AJ. Health care ethics consultation: an update on core competencies and emerging standards from the American Society For Bioethics and Humanities' core competencies update task force. Am J Bioeth 2013; 13:3-13. [PMID: 23391049 DOI: 10.1080/15265161.2012.750388] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report.
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Affiliation(s)
- Anita J Tarzian
- University of Maryland Francis King Carey School of Law, 500 W. Baltimore St., Baltimore, MD 21201, USA.
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Affiliation(s)
- Anita J Tarzian
- Maryland Healthcare Ethics Committee Network, University of Maryland School of Law, 500 W. Baltimore Street, Baltimore, MD 21201, USA.
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LaKind JS, Brent RL, Dourson ML, Kacew S, Koren G, Sonawane B, Tarzian AJ, Uhl K. Human milk biomonitoring data: interpretation and risk assessment issues. J Toxicol Environ Health A 2005; 68:1713-69. [PMID: 16176917 DOI: 10.1080/15287390500225724] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Biomonitoring data can, under certain conditions, be used to describe potential risks to human health (for example, blood lead levels used to determine children's neurodevelopmental risk). At present, there are very few chemical exposures at low levels for which sufficient data exist to state with confidence the link between levels of environmental chemicals in a person's body and his or her risk of adverse health effects. Human milk biomonitoring presents additional complications. Human milk can be used to obtain information on both the levels of environmental chemicals in the mother and her infant's exposure to an environmental chemical. However, in terms of the health of the mother, there are little to no extant data that can be used to link levels of most environmental chemicals in human milk to a particular health outcome in the mother. This is because, traditionally, risks are estimated based on dose, rather than on levels of environmental chemicals in the body, and the relationship between dose and human tissue levels is complex. On the other hand, for the infant, some information on dose is available because the infant is exposed to environmental chemicals in milk as a "dose" from which risk estimates can be derived. However, the traditional risk assessment approach is not designed to consider the benefits to the infant associated with breastfeeding and is complicated by the relatively short-term exposures to the infant from breastfeeding. A further complexity derives from the addition of in utero exposures, which complicates interpretation of epidemiological research on health outcomes of breastfeeding infants. Thus, the concept of "risk assessment" as it applies to human milk biomonitoring is not straightforward, and methodologies for undertaking this type of assessment have not yet been fully developed. This article describes the deliberations of the panel convened for the Technical Workshop on Human Milk Surveillance and Biomonitoring for Environmental Chemicals in the United States, held at the Hershey Medical Center, Pennsylvania State College of Medicine, on several issues related to risk assessment and human milk biomonitoring. Discussion of these topics and the thoughts and conclusions of the panel are described in this article.
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Affiliation(s)
- Judy S LaKind
- Department of Pediatrics, Milton S. Hershey Medical Center, Pennsylvania State University, College of Medicine, Hershey, PA 17033, USA.
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Berlin CM, LaKind JS, Fenton SE, Wang RY, Bates MN, Brent RL, Condon M, Crase BL, Dourson ML, Ettinger AS, Foos B, Fürst P, Giacoia GP, Goldstein DA, Haynes SG, Hench KD, Kacew S, Koren G, Lawrence RA, Mason A, McDiarmid MA, Moy G, Needham LL, Paul IM, Pugh LC, Qian Z, Salamone L, Selevan SG, Sonawane B, Tarzian AJ, Rose Tully M, Uhl K. Conclusions and recommendations of the expert panel: technical workshop on human milk surveillance and biomonitoring for environmental chemicals in the United States. J Toxicol Environ Health A 2005; 68:1825-31. [PMID: 16176920 DOI: 10.1080/15287390500226896] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Cheston M Berlin
- Department of Pediatrics, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.
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Abstract
BACKGROUND Individuals who are homeless may encounter various barriers to obtaining quality end-of-life (EOL) care, including access barriers, multiple sources of discrimination, and lack of knowledge among health care providers (HCPs) of their preferences and decision-making practices. Planning for death with individuals who have spent so much energy surviving requires an understanding of their experiences and preferences. OBJECTIVE This study sought to increase HCPs' awareness and understanding of homeless or similarly marginalized individuals' EOL experiences and treatment preferences. DESIGN Focus groups were conducted with homeless individuals using a semi-structured interview guide to elicit participants' EOL experiences, decision-making practices, and personal treatment preferences. SETTING/SUBJECTS Five focus groups were conducted with 20 inner-city homeless individuals (4 per group) at a free urban health care clinic for homeless individuals in the United States. Sixteen of the 20 participants were African American; 4 were Caucasian. None were actively psychotic. All had experienced multiple losses and drug addiction. FINDINGS Five main themes emerged: valuing an individual's wishes; acknowledging emotions; the primacy of religious beliefs and spiritual experience; seeking relationship-centered care; and reframing advance care planning. CONCLUSIONS The narrative process of this qualitative study uncovered an approach to EOL decision-making in which participants' reasoning was influenced by emotions, religious beliefs, and spiritual experience. Relationship-centered care, characterized by compassion and respectful, two-way communication, was obvious by its described absence--reasons for this are discussed. Recommendations for reframing advance care planning include ways for HCPs to transform advance care planning from that of a legal document to a process of goal-setting that is grounded in human connection, respect, and understanding.
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Affiliation(s)
- Anita J Tarzian
- University of Maryland, Baltimore, Maryland 21201-1786, USA.
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Abstract
OBJECTIVES The objective of this study was to identify pain management demographics, perceived resources, and perceived barriers to adequately manage pain in the nursing home setting. DESIGN Mailed survey. SETTING All licensed Connecticut nursing homes. PARTICIPANTS Directors of Nursing (DONs). MEASUREMENTS Survey eliciting pain management demographics, perceived resources, and perceived barriers to adequately manage pain in respondents' nursing home. RESULTS A total of 113 of 260 DONs (43%) responded to the survey. Respondents believed pain was suboptimally managed, particularly for residents with malignant and nonmalignant chronic pain. Perceived barriers to providing adequate pain management included lack of knowledge about pain management among nurses and physicians, lack of a standardized approach to treating pain, physicians' personal attitudes toward treating pain (eg, fear of addiction or overdose), lack of diagnostic precision in treating pain, and difficulty in choosing the right analgesic. Other barriers are also discussed, including low hospice enrollment of nursing home residents. CONCLUSION Improving pain management in nursing homes requires improving provider knowledge and attitudes, enhancing diagnostic precision, standardizing pain treatment, and achieving an institutional commitment. Although responding DONs seemed aware of the need for improved pain management outcomes at their facilities, the required institutional commitment to accomplish this was not evidenced by these findings.
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Affiliation(s)
- Anita J Tarzian
- Law and Health Care Program, University of Maryland School of Law, Baltimore, MD 21201-1786, USA.
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Abstract
The quality of end-of-life care in this country is often poor. There is abundant literature indicating that dying individuals do not receive adequate pain medication or palliative care, are tethered to machines and tubes in a way that challenges their dignity and autonomy, and are not helped to deal with the emotional grief and psychological angst that may accompany the dying process. While this is true for individuals in many settings, it seems to be especially true for individuals in nursing homes. This is somewhat puzzling given that (1) considerable resources have been devoted to bringing public attention to this problem, (2) we have the knowledge and expertise to provide such care, and (3) we have a government-financed benefit that covers this type of care - the Medicare hospice benefit (MHB).While utilization of hospice care has increased during the last decade, there is considerable evidence that hospice care remains underutilized particularly in the long term care setting.
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Affiliation(s)
- Diane E Hoffmann
- Law & Health Care Program at the University of Maryland School of Law, USA
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Abstract
OBJECTIVES The objective of this study was to identify pain management demographics, perceived resources, and perceived barriers to adequately manage pain in the nursing home setting. DESIGN Mailed survey. SETTING All licensed Connecticut nursing homes. PARTICIPANTS Directors of Nursing (DONs). MEASUREMENTS Survey eliciting pain management demographics, perceived resources, and perceived barriers to adequately manage pain in respondents' nursing home. RESULTS A total of 113 of 260 DONs (43%) responded to the survey. Respondents believed pain was suboptimally managed, particularly for residents with malignant and nonmalignant chronic pain. Perceived barriers to providing adequate pain management included lack of knowledge about pain management among nurses and physicians, lack of a standardized approach to treating pain, physicians' personal attitudes toward treating pain (eg, fear of addiction or overdose), lack of diagnostic precision in treating pain, and difficulty in choosing the right analgesic. Other barriers are also discussed, including low hospice enrollment of nursing home residents. CONCLUSION Improving pain management in nursing homes requires improving provider knowledge and attitudes, enhancing diagnostic precision, standardizing pain treatment, and achieving an institutional commitment. Although responding DONs seemed aware of the need for improved pain management outcomes at their facilities, the required institutional commitment to accomplish this was not evidenced by these findings.
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Affiliation(s)
- Anita J Tarzian
- University of Maryland School of Law, Baltimore, Maryland, USA.
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Tarzian AJ, Silverman HJ. Care coordination and utilization review: clinical case managers' perceptions of dual role obligations. J Clin Ethics 2003; 13:216-29. [PMID: 12624889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Anita J Tarzian
- University of Maryland School of Law and Health Care Program, Baltimore, Maryland, USA.
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Abstract
Uncertainty regarding potential disciplinary action may give physicians pause when considering whether to accept a chronic pain patient or how to treat a patient who may require long-term or high doses of opioids. Surveys have shown that physicians fear potential disciplinary acrion for prescribing controlled substances and that physicians will, in some cases, inadequately prescribe opioids due to fear of regulatory scrutiny. Prescribing opioids for long-term pain management, particularly noncancer pain management, has been controversial; and boards have investigated and, in some cases, disciplined physicians for such prescribing. While in virtually all of these cases the disciplinary actions were successfully appealed, news of the success was not often as well-publicized as news of the disciplinary actions, leaving some physicians confused about their potential liability when prescribing opioids for pain. The confusion has perhaps increased as a result of two relatively recent cases, one where a physician was successfully disciplined by a state medical board for undertreatment of his patients’ pain, and another where the physician was successfully sued for inadequate pain treatment.
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Affiliation(s)
- Diane E Hoffmann
- Law & Health Care Program, University of Maryland School of Law, USA
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Tarzian AJ, Davidson SM, Hoffmann DE. Management of cancer-related and noncancer-related chronic pain in Connecticut: successes and failures. Conn Med 2002; 66:683-9. [PMID: 12476511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Findings are reported from a survey of Connecticut HMO patients who had one of three conditions associated with pain: cancer, arthritis, and neuropathic diagnoses. From each group, 145 patients were randomly selected to receive a mailed survey. The overall eligible response rate was 73%. About two thirds had experienced pain for over a year, and the same percentage was experiencing pain at the time of the survey. Seventy-three percent of respondents with cancer pain (RCs) rated their pain in the moderate range, compared to 37.5% of respondents with arthritis pain (RAs) and neuropathic pain (RNPs). More RAs and RNPs (41.5%) rated their pain in the severe range. Twenty-three percent of both RCs and RAs and 31% of RNPs had received no effective treatment for their pain. The percentage of respondents using prescription narcotics at the time of the survey was low (16%), and had dropped by almost half from the proportion using them in the past (29%). Side effects of pain medications and attitudes toward opioids were implicated as reasons for discontinuing pain medications. Respondents described substantial negative impact of pain on their abilities to perform various activities, but this had improved from the time when they first experienced their pain. Overall, the findings indicate that improvements have been made in the treatment of pain, particularly for patients with cancer pain. There is still room for improvement, particularly for individuals with chronic neuropathic pain. Specific recommendations are discussed.
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Affiliation(s)
- Anita J Tarzian
- University of Maryland School of Law, Baltimore, Maryland, USA
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Tarzian AJ, Silverman HJ. Care Coordination and Utilization Review: Clinical Case Managers’ Perceptions of Dual Role Obligations. The Journal of Clinical Ethics 2002. [DOI: 10.1086/jce200213304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
This phenomenological study explored the perceptions of 20 patients who had undergone an autologous bone marrow transplantation (ABMT). Transcripts from interviews were analyzed for themes. Three themes emerged related to the experience of isolation during and after ABMT: physical isolation (protecting self and others), emotional isolation (protecting self and others), and physical and emotional isolation (supporting self and others). During physical isolation, participants were protected from infection and tried to protect family and friends from emotional burden. However, physical isolation often led to emotional isolation, which the physical presence of others ameliorated, particularly when an emotional presence was coexistent. Emotional presence was a main source of social support. Participants felt family and friends needed more guidance on ways to provide effective support. An important implication for health care professionals is that emotional support in the form of positive presencing should accompany providing information to both patients and family members.
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Affiliation(s)
- M Z Cohen
- Health Science Center, School of Nursing, University of Texas, M. D. Anderson Cancer Center, USA
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Abstract
PURPOSE To describe the experience and meaning of breast cancer screening for African American women. Breast cancer screening offers the greatest hope of reducing breast cancer mortality and improving breast cancer outcomes. Despite the proliferation of initiatives targeting African American women, they continue to be first diagnosed only when they have late-stage disease. DESIGN AND METHODS Using hermeneutic phenomenological research methods, 23 low- and middle-income African American women were interviewed to gain an understanding of their experiences with breast cancer screening. FINDINGS Participants varied in their experiences with breast cancer screening. Women spoke of a desire for a holistic approach to health that did not separate the breast from the rest of the body. This desire is indicated in the theme of minding the body, self, and spirit, along with themes of relationships and spreading the word about breast health issues. CONCLUSIONS Interventions for African American women should include a focus on minding the body, self, and spirit to promote breast cancer screening, and should indicate the importance of relationships and spreading the word about breast cancer screening.
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Affiliation(s)
- J M Phillips
- National Institute of Nursing Research, 45 Center Drive, MSC 6300, Bethesda, MD 20892-6300, USA.
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Abstract
To the woman, God said, “I will greatly multiply your pain in child bearing; in pain you shall bring forth children, yet your desire shall be for your husband, and he shall rule over you.”Genesis 3:16There is now a well-established body of literature documenting the pervasive inadequate treatment of pain in this country. There have also been allegations, and some data, supporting the notion that women are more likely than men to be undertreated or inappropriately diagnosed and treated for their pain.One particularly troublesome study indicated that women are more likely to be given sedatives for their pain and men to be given pain medication. Speculation as to why this difference might exist has included the following: Women complain more than men; women are not accurate reporters of their pain; men are more stoic so that when they do complain of pain, “it's real”; and women are better able to tolerate pain or have better coping skills than men.
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Affiliation(s)
- D E Hoffmann
- Faculty & External Affairs, Law & Health Care Program, University of Maryland School of Law, USA
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Abstract
PURPOSE To understand nurses' experiences of caring for dying patients who have "air hunger." When air hunger occurs in people who are close to death, it often triggers increasing panic and breathlessness. Describing this phenomenon is an initial step toward a more informed and consistent response to air-hungry patients. DESIGN AND METHODS Phenomenological study of 10 hospice, long-term care, oncology, or emergency medicine nurses who cared for air-hungry dying patients. Analysis was based on van Manen's guidelines for interpretive phenomenology. Interviews with two family members who witnessed their dying spouses suffer from air hunger were used to complement the nurses' accounts. FINDINGS Themes of (a) the patient's look-panic beckons, (b) surrendering and sharing control, and (c) fine-tuning dying indicated ways nurses responded to relieve a patient's air hunger, including being prepared before air hunger occurs, calming patients and families, medicating patients, improvising care, attending to family members' needs, and drawing a distinction between palliating and killing. CONCLUSIONS The three themes provide a framework for a new vision of "doing everything" for a dying person who suffers from air hunger. Care encompasses knowing what to do as well as how to stay present during suffering.
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Affiliation(s)
- A J Tarzian
- Law and Health Program, University of Maryland, School of Law, Baltimore 21201, USA.
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Abstract
Phenomenologic inquiry was used to explore patients' experiences with autologous bone marrow transplantation (ABMT). Interviews were conducted before and after implementation of a clinical pathway that included a teaching protocol for ABMT. Texts were analyzed individually, compared for pre- and postpathway patients to determine if different themes emerged from these two groups, and then combined. Themes common to both groups included (a) a range of needs for information, (b) everybody's different: a fine balance (the challenge of finding a balance when giving information to patients who vary in the amount of information they desire), (c) someone who has been there (the value of talking to someone who has survived an ABMT), (d) and the burden of ABMT patients teaching family. One theme that reflected different experiences of pre- and postpathway patients was that of the need to know detailed information about the ABMT and the fear of knowing too much. Whereas postpathway patients reflected more on the burden of knowing too much, prepathway patients expressed more dissatisfaction about not being told enough about procedures and symptoms to be expected. Suggestions for teaching patients about ABMT include being generally realistic while focusing on the positive, and viewing patient education as a process individualized according to each patient's needs.
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Affiliation(s)
- A J Tarzian
- School of Nursing, University of Maryland, Baltimore, USA
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Abstract
Healthcare reform has been a major economic and political focus throughout the 1990s. In a national survey of registered nurses about work life and health, many narrative comments addressed changes in the healthcare system. This qualitative study an analysis of these comments, identified themes related to nurses' perceptions of changes and the effect of healthcare reform on the practice of nursing.
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Affiliation(s)
- P Corey-Lisle
- University of Maryland School of Nursing, Baltimore, USA.
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Tarzian AJ. Last rites. Hastings Cent Rep 1995; 25:3. [PMID: 8609017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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