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Abstract
Goals of care conversations are important but complex for clinicians caring for older adults. Although clinicians tend to focus on specific medical interventions, these conversations are more successful if they begin with gaining a shared understanding of the medical conditions and possible outcomes, followed by discussion of values and goals. Although training in the medical setting is incomplete, there are many published and online resources that can help clinicians gain these valuable skills.
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Affiliation(s)
- Amber Comer
- School of Health and Human Sciences, Indiana University, 1050 Wishard Boulevard, RG 3034, Indianapolis, IN 46202, USA
| | - Lyle Fettig
- Division of General Medicine and Geriatrics, Palliative Care, Indiana University School of Medicine, Eskenazi Health, 640 Eskenazi Avenue, Indianapolis, IN 46202, USA
| | - Alexia M Torke
- Division of General Medicine and Geriatrics, Indiana University School of Medicine, Indiana University Center for Aging Research, Regenstrief Institute, Incorporated, 1101 West 10th Street, Indianapolis, IN 46202, USA.
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2
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Abstract
As I organize a pile of ethics consult chart notes in New York City in mid‐April 2020, I look at the ten cases that I have co‐consulted on recently. Nine of the patients were found to be Covid positive. The reasons for the consults are mostly familiar—surrogate decision‐making, informed refusal of treatment, goals of care, defining futility. But the context is unfamiliar and unsettling. Bioethicists are in pandemic mode, dusting off and revising triage plans. Patients and potential patients are fearful—of the disease itself and of the amplification of health disparities and inequities. There is much to contemplate, but as I go through my cases, I worry about disability, about biases and racist stereotypes. In this pandemic, historically marginalized communities are at risk of further disenfranchisement.
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3
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Abstract
Palliative medicine is a specialty that focuses on improving the quality of life for patients with serious or advanced medical conditions, and it is appropriate at any stage of disease, including at the time of diagnosis. Neurologic conditions tend to have high symptom burdens, variable disease courses, and poor prognoses that affect not only patients but also their families and caregivers. Patients with a variety of neurologic conditions such as Parkinson disease, dementia, amyotrophic lateral sclerosis, brain tumors, stroke, and acute neurologic illnesses have substantial unmet needs that can be addressed through a combination of primary and specialty palliative care. The complex needs of these patients are ideally managed with a comprehensive approach to care that addresses the physical, psychological, social, and spiritual aspects of care in an effort to reduce suffering. Early discussions about prognosis, goals of care, and advance care planning are critical as they can provide guidance for treatment decisions and allow patients to retain a sense of autonomy despite progressive cognitive or functional decline. With the rapid growth in palliative care across the United States, there are opportunities to improve the palliative care knowledge of neurology trainees, the delivery of palliative care to patients with neurologic disease by both neurologists and nonneurologists, and the research agenda for neuropalliative care.
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Affiliation(s)
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
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4
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Johnson KL, Alsharif NZ, Rovers J, Connor S, White ND, Hogue MD. Recommendations for Planning and Managing International Short-term Pharmacy Service Trips. Am J Pharm Educ 2017; 81:23. [PMID: 28381883 PMCID: PMC5374912 DOI: 10.5688/ajpe81223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/04/2016] [Indexed: 06/07/2023]
Abstract
International pharmacy service trips by schools and colleges of pharmacy allow students to provide health care to medically underserved areas. A literature review (2000-2016) in databases and Internet searches with specific keywords or terms was performed to assess current practices to establish and maintain successful pharmacy service trips. Educational documents such as syllabi were obtained from pharmacy programs and examined. A preliminary draft was developed and authors worked on sections of interest and expertise. Considerations and current recommendations are provided for the key aspects of the home institution and the host country requirements for pharmacy service trips based on findings from a literature search and the authors' collective, extensive experience. Evaluation of the trip and ethical considerations are also discussed. This article serves as a resource for schools and colleges of pharmacy that are interested in the development of new pharmacy service trips and provides key considerations for continuous quality improvement of current or future activities.
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5
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Smith KL, Fedel P, Heitman J. Incapacitated Surrogates: A New and Increasing Dilemma in Hospital Care. J Clin Ethics 2017; 28:279-289. [PMID: 29257763] [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: 06/07/2023]
Abstract
A power of attorney for healthcare (POAHC) form gives designated individuals legal status to make healthcare decisions when patients are unable to convey their decisions to medical staff. Completion of a POAHC form is crucial in the provision of comprehensive healthcare, since it helps to ensure that patients' interests, values, and preferences are represented in decisions about their medical treatment. Because increasing numbers of people suffer from debilitating illness and cognitive deficits, healthcare systems may be called upon to navigate the complexities of patients' care without clear directives from the patients themselves. Hence, the healthcare industry encourages all individuals to complete a POAHC form to ensure that persons who have the patients' trust are able to act as their surrogate decision makers. However, sometimes POAHC agents, even when they are patients' trusted agents, lack the capacity to make fully informed decisions that are in the patients' best interests. We describe designated surrogate decision makers who have impaired or diminished judgment capacity as incapacitated surrogates. Decision making that is obviously flawed or questionable is a significant impediment to providing timely and appropriate care to patients. Moreover, failure to redress these issues in a timely and efficient manner can result in significant costs to an institution and a diminished quality of patient care. The authors offer a legal, ethical, and interdisciplinary framework to help navigate cases of incapacitated surrogates.
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Affiliation(s)
| | | | - Jay Heitman
- Ascension Wisconsin, Milwaukee, Wisconsin USA.
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6
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Abstract
The aim of this study was to increase understanding of how individual patient care and the ethical principles prescribed for nursing care are implemented in nursing documentation. The method used was a metasynthesis of the results of 14 qualitative research reports. The results indicate that individualized patient care is not visible in nurses’ documentation of care. It seems that nurses describe their tasks more frequently than patients’ experiences of their care. The results also show that the structure of nursing documentation and the forms or manner of recording presupposed by the organization may prevent individual recording of patient care. In order to obtain visibility for good patient-centred and ethical nursing care, an effort should be made to influence how the content of nursing care is documented and made an essential part of individual patient care. If the content of this documentation does not give an accurate picture of care, patients’ right to receive good nursing care may not be realized.
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7
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Hansen H. Undertreatment, an Ethical Issue. J Calif Dent Assoc 2016; 44:467. [PMID: 27514159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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8
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Moses L, Kodner IJ, Brown D, Nussenbaum B, Yu J. Seeking equilibrium in decision making: The balance between clinical judgment and patient goals. Bull Am Coll Surg 2016; 101:24-29. [PMID: 28941445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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9
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Chih AH, Su P, Hu WY, Yao CA, Cheng SY, Lin YC, Chiu TY. The Changes of Ethical Dilemmas in Palliative Care. A Lesson Learned from Comparison Between 1998 and 2013 in Taiwan. Medicine (Baltimore) 2016; 95:e2323. [PMID: 26735533 PMCID: PMC4706253 DOI: 10.1097/md.0000000000002323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The current ethical dilemmas met by healthcare professionals were never compared with those 15 years ago when the palliative care system was newly developing in Taiwan. The aim of the study was to investigate the ethical dilemmas met by palliative care physicians and nurses in 2013 and compare the results with the survey in 1998. This cross-sectional study surveyed 213 physicians and nurses recruited from 9 representative palliative care units across Taiwan in 2013. The compared survey in 1998 studied 102 physicians and nurses from the same palliative care units. All participants took a questionnaire to survey the "frequency" and "difficulty" of 20 frequently encountered ethical dilemmas, which were grouped into 4 domains by factor analysis. The "ethical dilemma" scores were calculated and then compared across 15 years by Student's t tests. A general linear model analysis was used to identify significant factors relating to a high average "ethical dilemma" score in each domain. All of the highest-ranking ethical dilemmas in 2013 were related to insufficient resources. Physicians with less clinical experience had a higher average "ethical dilemma" score in clinical management. Physicians with dissatisfaction in providing palliative care were associated a higher average "ethical dilemma" score in communication. Nurses reported higher "ethical dilemma" scores in all items of resource allocation in 2013. Further analysis confirmed that, in 2013, nurses had a higher average "ethical dilemma" score in resource allocation after adjustment for other relating factors. Palliative care nursing staff in Taiwan are more troubled by ethical dilemmas related to insufficient resources than they were 15 years ago. Training of decision making in nurses under the framework of ethical principles and community palliative care programs may improve the problems. To promote the dignity of terminal cancer patients, long-term fundraising plans are recommended for countries in which the palliative care system is in its early stages of development.
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Affiliation(s)
- An-Hsuan Chih
- From the Health Center, Office of Student Affairs, National Taiwan University (A-HC); Department of Audiology and Speech-Language Pathology, Mackay Medical College (P-JS); Department of Family Medicine, Mackay Memorial Hospital (P-JS); School of Nursing (W-YH); and Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taiwan (C-AY, S-YC, Y-CL, T-YC)
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10
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Terry BR. Why Is It Ethical? Pa Dent J (Harrisb) 2016; 83:5-6. [PMID: 26925487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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11
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Abstract
Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive.
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12
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Greco PM. How much is too much? Am J Orthod Dentofacial Orthop 2015; 148:209. [PMID: 26232827 DOI: 10.1016/j.ajodo.2015.06.003] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 06/01/2015] [Accepted: 06/01/2015] [Indexed: 11/18/2022]
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13
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Abstract
Futility has been a contentious topic in medicine for several decades. Surgery in critical or end-of-life situations often raises difficult questions about futility. In this article, we discuss the definition of futility, methods for resolving futility disputes, and some ways to reframe the futility debate to a more fruitful discussion about the goals of care, better communication between surgeon and patient/surrogate, and palliative surgical care. Many definitions of futile therapy have been discussed. The most controversial of these is "qualitative futility" which describes a situation in which the treatment provided is likely to result in an unacceptable quality of life. This is an area of continued controversy because it has been impossible to identify universally held beliefs about acceptable quality of life. Many authors have described methods for resolving futility disputes, including community standards and legalistic multi-step due process protocols. Others, however, have abandoned the concept of futility altogether as an unhelpful term. Reframing the issue of futility as one of inadequate physician-patient communication, these authors have advocated for methods of improving communication and strengthening the patient-physician relationship. Finally, we discuss the utilization of consultants who may be of use in resolving futility disputes: ethics committees, palliative care specialists, pastoral care teams, and dedicated patient advocates. Involving these specialists in a futility conflict can help improve communication and provide invaluable assistance in arriving at the appropriate treatment decision.
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Affiliation(s)
- Scott B Grant
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, 08901, USA
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14
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Arcand M. End-of-life issues in advanced dementia: Part 1: goals of care, decision-making process, and family education. Can Fam Physician 2015; 61:330-334. [PMID: 25873700 PMCID: PMC4396757] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To review the issues with setting goals of care for patients with advanced dementia, describe the respective roles of the physician and the patient's family in the decision-making process, and suggest ways to support families who need more information about the care options. SOURCES OF INFORMATION Ovid MEDLINE was searched for relevant articles that were published before March 7, 2014. There were no level I studies identified; most articles provided level III evidence. MAIN MESSAGE For patients with advanced dementia, their families have an important role in medical decision making. Families should receive timely information about the course of dementia and the care options. They need to understand that a palliative approach to care might be appropriate and does not mean abandonment of the patient. They might also want clarification about their role in the decision-making process, especially if withholding or withdrawing life-prolonging measures are considered. CONCLUSION Physicians should consider advanced dementia as a terminal disease for which there is a continuum of care that goes from palliative care with life-extending measures to symptomatic interventions only. Clarification of goals of care and family education are of paramount importance to avoid unwanted and burdensome interventions.
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Affiliation(s)
- Marcel Arcand
- Full Professor in the Department of Family Medicine at the University of Sherbrooke in Quebec, a care of the elderly physician at Institut universitaire de gériatrie de Sherbrooke, and a researcher at the Centre de recherche sur le vieillissement in Sherbrooke.
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15
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Holwager D. HIP 2.0: Plan Limitations Lead to Ethical Dilemmas. J Indiana Dent Assoc 2015; 94:24-26. [PMID: 26817048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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16
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Bush DM. "How Dentists Rip Us Off". J Indiana Dent Assoc 2015; 94:10-11. [PMID: 26817043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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17
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Shetter N. What are we going to do about grandpa? J Mich Dent Assoc 2014; 96:48-50. [PMID: 25318198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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18
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Naidoo S, du Toit J. Planning for treatment ethically. SADJ 2014; 69:374-375. [PMID: 26548229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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19
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Friedmann R. [Questioning old thinking patterns]. Pflege Z 2014; 67:498-502. [PMID: 25154081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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20
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Greco PM. Ethics in orthodontics. Joint autonomy. Am J Orthod Dentofacial Orthop 2014; 145:716. [PMID: 24880840 DOI: 10.1016/j.ajodo.2014.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 11/18/2022]
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21
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Naidoo S. Over-servicing. SADJ 2014; 69:230-231. [PMID: 26548192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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22
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Naidoo S, du Toit J. Ethical issues in replacing a single tooth with a dental implant. SADJ 2014; 69:176-177. [PMID: 24984394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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23
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Affiliation(s)
- Bruce S Haskell
- Bruce S. Haskell, DMD, PhD is Professor (part-time) at the University of Kentucky, College of Dentistry, Division of Orthodontics, and Distinguished Teaching Professor (part-time) at the University of Louisville School of Dentistry
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24
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Camm J. Creative diagnosis: a new dental skill? J Mich Dent Assoc 2013; 95:42-43. [PMID: 24558720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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25
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Maihofer M. Completing another dentist's treatment plan. J Mich Dent Assoc 2013; 95:24-62. [PMID: 24558715] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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26
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Winkler D. Putting the ethics into aesthetic dentistry. Prim Dent J 2013; 2:4. [PMID: 24466614 DOI: 10.1308/205016814809859428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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27
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Davies J, Black S, Bentley N, Nagi C. Forensic case formulation: theoretical, ethical and practical issues. Crim Behav Ment Health 2013; 23:304-14. [PMID: 24101410 DOI: 10.1002/cbm.1882] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/17/2013] [Accepted: 07/23/2013] [Indexed: 05/22/2023]
Abstract
ARGUMENT Forensic case formulation, of increasing interest to practitioners and researchers raises many ethical, theoretical and practical issues for them. CONCLUSION Systemic, contextual and individual factors which need to be considered include the multitude of staff often involved with any one individual, the pressure to 'get it right' because of the range of risk implications that are associated with individuals within forensic mental health settings, and individual parameters, for example reluctance to be engaged with services.
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Affiliation(s)
- Jason Davies
- Abertawe Bro Morgannwg University Health Board, Cefn Coed Hospital, Cockett, Swansea, UK; School of Medicine, Swansea University, Swansea, UK
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28
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Naidoo S. Ethics corner. Periodontal treatment & allegations of neglect. SADJ 2013; 68:84-87. [PMID: 23951771] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- S Naidoo
- Faculty of Dentistry, University of the Western Cape.
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29
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Kurkowski MA. Let's get personal. Northwest Dent 2013; 92:41. [PMID: 23516719] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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30
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Whetton S. Using personal health information: do we manage conflicting interests? Stud Health Technol Inform 2013; 188:135-141. [PMID: 23823301] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The discipline of health informatics is concerned with developing the information systems that facilitate collection, manipulation and dissemination of personal health information. It promotes the benefits of using personal health information for secondary purposes, including policy development, service planning and research. At the same time the health informatics community is a strong advocate of privacy and the need to protect individuals from negative consequences arising from unauthorised use of their personal health information. This creates a dilemma for health informatics professionals since there will be occasions when the rights and interests of individuals conflict with the rights and interests of the public, or particular sections of the public. In such instances, the community as a whole, and individual members, may be required to take a stance on whether to prioritise privacy over public needs and interests. Such instances are likely to increase in the future as demands for access to personal health information increase. This paper considers the way the health informatics community approaches the dilemma. It reports on a study which analysed various perspectives on the issue as expressed in HISA conference proceedings. The study identified six discourses, each of which focuses on different uses of personal health information. The study found that the discourses expressed strong support for expanded use of personal health information where the public interest was convincingly argued, although the interpretation of what constituted public interest varied between the discourses. The study also found that while higher level discussions highlight the potential for negative consequences arising from expanded uses of personal health information, this was not often discussed in the conference texts. It is argued that such concerns should be considered, particularly in the light of discussions around the Commonwealth government's Individual Health Identifier and Personally Controlled Electronic Health Records initiatives.
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Affiliation(s)
- Sue Whetton
- University Department of Rural Health, Tasmania
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31
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Ozar DT. Professionalism: challenges for dentistry in the future. J Forensic Odontostomatol 2012; 30 Suppl 1:72-84. [PMID: 23221268] [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: 06/01/2023]
Abstract
While countries varies significantly in the financing of dental care, they are much more alike in the delivery of dentistry. Dental care is principally provided in dental offices and clinics that are independent business entities whose business leaders are most often the dentists themselves. However society expects from dentists a level of professionalism (i.e. habitually acting ethically, both in terms of competence and conduct) in contrast to the methods and motivations of the marketplace. This is why the single most important challenge of dental professional ethics continues to be giving proper priority to patients' well being and building ethically correct decision-making relationships with patients while, at the same time, trying to maintain a successful business operation. If we look into dentistry's future, the centrality of this aspect of professional ethics is not likely to change, although the ways in which dentists might violate this trust will probably multiple as funding mechanisms become increasingly complex. It is important that dentists reflect with fresh eyes on their ethical commitments. One challenge is the increased availability of oral health information to the public and the fact that so many people are uncritical of the accuracy of information in the media and on the web. A second is the increase in the amount of health care advertising in many societies. A third is the growth of aesthetic dentistry that differs from standard oral health care in important and ethically significant ways. The fourth is insurance that frequently complicates the explanation of a patient's treatment alternatives and often brings a third party into the treatment decision relationship. The ethical challenges of each of these factors will be considered and ultimately tying it to the central theme of dental professionalism.
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Affiliation(s)
- D T Ozar
- Department of Philosophy, Loyola University Chicago, USA.
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32
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Bright PL, Nelson RM. A capacity-based approach for addressing ancillary care needs: implications for research in resource limited settings. J Med Ethics 2012; 38:672-676. [PMID: 22562947 DOI: 10.1136/medethics-2011-100205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A paediatric clinical trial conducted in a developing country is likely to encounter conditions or illnesses in participants unrelated to the study. Since local healthcare resources may be inadequate to meet these needs, research clinicians may face the dilemma of deciding when to provide ancillary care and to what extent. The authors propose a model for identifying ancillary care obligations that draws on assessments of urgency, the capacity of the local healthcare infrastructure and the capacity of the research infrastructure. The model lends itself to a decision tree that can be adapted to the local context and resources so as to provide procedural guidance. This approach can help in planning and establishing organisational policies that govern the provision of ancillary care.
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Janssens R, van Delden JJM, Widdershoven GAM. Palliative sedation: not just normal medical practice. Ethical reflections on the Royal Dutch Medical Association's guideline on palliative sedation. J Med Ethics 2012; 38:664-668. [PMID: 22811556 DOI: 10.1136/medethics-2011-100353] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [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
The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny the ethical distinctions between euthanasia and palliative sedation, we will critically analyse the guideline's argumentation strategy with which euthanasia is demarcated from palliative sedation. First, we will analyse the guideline's main premise, which entails that palliative sedation is normal medical treatment. After this, we will critically discuss three crucial propositions of the guideline that are used to support this premise: (1) the patient's life expectancy should not exceed 2 weeks; (2) the aim of the physician should be to relieve suffering and (3) expert consultation is optional. We will conclude that, if inherent problematic aspects of palliative sedation are taken seriously, palliative sedation is less normal than it is now depicted in the guideline.
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Affiliation(s)
- Rien Janssens
- Department of Medical Humanities, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, Netherlands.
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34
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Roucka TM. Dental assistant or patient? Can she be both? Gen Dent 2012; 60:461-463. [PMID: 23220300] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Toni M Roucka
- General Dentistry, Marquette University School of Dentistry, Milwaukee, Wisconsin, USA
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35
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Abstract
Contrary to the widespread concern about over-treatment at the end of life, today, patient preferences for palliative care at the end of life are frequently respected. However, ethically challenging situations in the current healthcare climate are, instead, situations in which a competent patient requests active treatment with the goal of life-prolongation while the physician suggests best supportive care only. The argument of futility has often been used to justify unilateral decisions made by physicians to withhold or withdraw life-sustaining treatment. However, we argue that neither the concept of futility nor that of patient autonomy alone is apt for resolving situations in which physicians are confronted with patients' requests for active treatment. Instead, we integrate the relevant arguments that have been put forward in the academic discussion about 'futile' treatment into an ethical algorithm with five guiding questions: (1) Is there a chance that medical intervention will be effective in achieving the patient's treatment goal? (2) How does the physician evaluate the expected benefit and the potential harm of the treatment? (3) Does the patient understand his or her medical situation? (4) Does the patient prefer receiving treatment after evaluating the benefit-harm ratio and the costs? (5) Does the treatment require many resources? This algorithm shall facilitate approaching patients' requests for treatments deemed futile by the physician in a systematic way, and responding to these requests in an ethically appropriate manner. It thereby adds substantive considerations to the current procedural approaches of conflict resolution in order to improve decision making among physicians, patients and families.
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Affiliation(s)
- Eva C Winkler
- National Center for Tumour Diseases, University of Heidelberg, Heidelberg, Germany.
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36
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Levin L. Ethics in the dental implant era. Quintessence Int 2012; 43:351. [PMID: 22536585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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37
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Heckmann SM. Ethics in dentistry and Konigsberg. Quintessence Int 2012; 43:177-178. [PMID: 22299116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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38
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Peltier B, Vernillo A, Giusti L, Jenson LE. Different labs. J Am Coll Dent 2012; 79:56-63. [PMID: 23654165] [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: 06/02/2023]
Abstract
In this case a young dentist has signed onto a managed care plan that has several attractive features. Eventually, however, he notices that he makes little or no net revenue for some of the work that he does. A colleague recommends that he use different labs for different patients, with labs matched to each patient's dental plan and coverage. Offshore labs are used for managed care patients. Three knowledgeable experts comment on the case, two with many years of private practice experience, two who are dental educators holding master's degrees in philosophy and bioethics.
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Affiliation(s)
- Bruce Peltier
- Dugoni School of Dentistry, University of the Pacific, San Francisco, USA.
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39
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Dodero M. [The ethical, legislative and regulatory basis of therapeutic education]. Soins Psychiatr 2011:16-18. [PMID: 21462490] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Beyond its interest in the field of public health and the political aspect with the "Hospital, patients, health and territories" law, therapeutic education now occupies an important place in nursing care. This new nursing culture provides another clinical approach for the nurse and a real means of learning for the patient in the framework of a support and guidance plan drawn up together.
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Naidoo S. Dental ethics case 8. Patient declines my proposed treatment plan. SADJ 2011; 66:34. [PMID: 21510176] [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] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- S Naidoo
- Department of Community Oral Health, University of the Western Cape, Private Bag XI, Tygerberg 7505.
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41
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Nunes A. Personal ethical dilemma: is the patient competent? J Am Coll Dent 2011; 78:19-21. [PMID: 22416613] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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42
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Gold F, Lointier F. [Ethics of the care given to premature newborns]. Soins Pediatr Pueric 2010:27-29. [PMID: 20925304] [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: 05/30/2023]
Abstract
The treatment of premature newborns has evolved a lot in France over the last decade. It can be examined with regard to the four main principles of biomedical ethics: beneficence, non-maleficence, autonomy and justice. Consequently the combination of medical-nursing vigilance and individualised developmental care enables the premature baby to benefit from truly "ethical" healthcare.
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43
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Touzet P. [From policy to unique care in psychiatry, the place of ethics]. Soins Psychiatr 2010:30-33. [PMID: 20925188] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Ethical reflection is an aid to psychiatrists in their role as caregiver and policy implementer. Ethics takes root in commitment, the act of resistance enables the caregiver not to be carried away by the dominant approach, but rather to be an individual subject respecting the singularity of others.
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44
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Tregouet S. [The ethics of the nursing commitment in psychiatry]. Soins Psychiatr 2010:24-26. [PMID: 20925186] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The referral nurse represents the care environment, he/she is the guarantor of the care plan and forms a commitment with regard to the patient. This positioning, arising from the empathy he/she has for the patient in a situation of vulnerability, may lead him/her to object to and question a medical decision.
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45
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Lubell J. End-of-life care. Advance directives have value, but some in industry cite drawbacks, too. Mod Healthc 2010; 40:30-31. [PMID: 20873665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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46
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Holt VP. The 'daughter test' in aesthetic ('esthetic') or cosmetic dentistry. Dent Update 2010; 37:337-338. [PMID: 20669713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Burke FJT. Dentist wealthy, patient healthy? Dent Update 2010; 37:277. [PMID: 20669704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Affiliation(s)
- Robert D Truog
- Harvard Medical School, Division of Medical Ethics, 641 Huntington Avenue, Boston, MA 02115, USA.
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49
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Pope TM. Restricting CPR to patients who provide informed consent will not permit physicians to unilaterally refuse requested CPR. Am J Bioeth 2010; 10:82-83. [PMID: 20077353 DOI: 10.1080/15265160903460996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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50
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Affiliation(s)
- Carolyn Ells
- McGill University, Biomedical Ethics Unit, 3647 Peel St., #305, Montreal, Quebec, H3A 1X1, Canada.
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