Ethical Situations, infectious diseases, euthanasia communication with patients, adherence, sick role Flashcards
Patient is not adherent
Attempt to identify the reason for nonadhetence and determine his willingness to change
Do not coerce the patient into adhering or refer him/her to another physician
Patient desires an unnecessary procedures
Attempt to understand why
Address UNDERLINE concerns
Do not refuse to see the patient or refer to another physician
Avoiding performing unnecessary procedures
Patient has difficulty taking medications
Provide written instructions
Attempt to simplify treatment regimen
Use teach-back method (ask patient to repeat medication refimen back to physician) to ensure patient comprehension
Family members ask for informations about patient’s prognosis
Avoid discussing issues with relatives without the patient’s permission
A patient’s family member asks you not to disclose the results of a test if the prognosis is poor because the patient will be “unable to handle it”
Attempt to identify why the family member believes such information would be detrimental to the patient’s condition
Explain that as long as the patient has decision making capacity and does not indicate otherwise, communication of information concerning his/her care will not be withheld
A child wishes to know more about his/her illness
Ask what the parents have told the child about his/her illness. Parents of a child decide what information can be relayed about the illness
a 17 years old is pregnant and request an abortion
Many states requires parental notification or consent for minors for an abortion.
Unless there are specific medical risk associated with pregnancy, a physician should not attempt to sway the decision of the patient to have an elective abortion (regardless of maternal age or fetal condition)
Patient is suicidal
Assess the seriousness of the treat
If it is serious, suggest that the patient remain in the hospital voluntarily
Patient can be hospitalized involuntarily if he/she refuses
15 year old girl pregnant and wants to keep the child. Her parents wants you to tell her to give her chid for adoption
The patient retains the right to make decision regarding the child, even if her parents disagre
Provide information to the teenager about the practical issues of caring a baby
Discuss the options, if requested.
Encourage discussion between teenager - parents
A terminally ill patient request physician assistance in ending his/her own life
In the overwhelming majority of states, refuse involvement in any form of physician assisted suicide
Physician may however prescribe medically appropriate analgesic that coincidentally shorten the patient’s life
A woman who had mastectomy says she now feels ugly
Find out why the patient feels this way
Do not offer falsely reassuring statement (“you still look good”)
Patient states that he/she finds you attractive
Ask direct, close ended questions and use chaperon if necessary.
Romantic relationships with patients are never appropriate.
Never say “there can be no relationship while you are a patient” because this implies that a relationship may be possible if the individual is no longer a patient
Patient is angry about the amount of time he/she spent in the waiting room
Acknowledge the patients anger, but do not take a patient’s anger personally.
Apologize for any inconvenience
Stay away from efforts to explain the delay
Patient is upset with the way he/she was treated by another doctor
Suggest that the patient speak directly to that physician regarding his/her concerns.
If the problem is with a member of the office staff, tell the patient you will speak to that person
An invasive test is perform on the wrong patient
Regardless of the outcome, a physician is ethically obligated to inform a patient that a mistake has been made
A patient requires a treatment not covered by his/her insurance
Never limit or deny care because of the expense in time or money.
Discuss all treatment options with patients, even if some are not covered by their insurance companies
A 7-years boy loses a sister to cancer and now fells responsible
At ages 5-7, children begin to understand that death is permanent, that all life functions end completely at death, and that everything that is alive eventually dies –> Provide a dierce, concrete description of his sister’s death. Avoid clishes and euphemisms. REASSURE THAT THE BOY IS NOT RESPONSIBLE. Identify and normalize fears and feelings. Encourage to play and healthy coping behaviours (eg. remembering her in his own way)
legal standard of death in US (when a person’s death is beating)?
irreversible cessation of all functions of the entire brain, including the brainstem –> the doctor is autorized to remove life support
a patients organs after death
cannot be harvest, unless the patient (or parent of a minor) has signed a document (eg. organ donor card) or informed surrogates wish to donate
euthanasia in usa - legal?
in ALL states (and according to medical codes of ethics) –> it is a CRIMINAL ACT
physician assisted aid in dying in USA- legal
it is legal in a very few states in CAREFUL selected patients
USA - analgesia that coincidentally shorten life
it is legal and ethical to provide MEDICALLY NEEDED ANALGESIA to termiante ill patient, even if it coincidentally will shorten the patient’s life
infections - usa - most states require physicians to report
varicella (chicken box), hepatitis, MMR
salmonela, shigella, TB, syphilis, gonorrhea, chlamydia
AIDS (or HIV without AIDS)
HIV + physician
Physicians are not required to inform either patients or the medical establishment about another physician’s HIV + status. an HIV + physicians who follows procedures for infection control does not pose a risk on patients
can a physician refuse to treat a patient because of fear of infection (eg. TB)
it is legally to refuce but it is UNETHICAL
physician has the right to inform somebody for the HIV+ status of another patient
HIV + patients must protect their sexually partners. If they fail or refuse and the physician has knowlegde of this, the physician can inform the threatened partner
Referral a patient to another physician - when
should be reserved for MEDICAL REASONS outside the range of the physician
Interviewing techniques - direct questions?
are used to elicit informations quickly in an emergency situation, or when the patient is seductive or overly talkative
Interviewing techniques - open ended question?
are used to obtain as much information as possible and encourage the patient to speak freely
Interviewing techniques - children with difficulty to respond - techniques
- question in third person (eg. what do you think a child who is scared would want the doctor to say)
- non-verbal means of expression (eg. lets draw a picture together of someone going to the doctor’s office
42 years old complains about how disorganized the doctor office is
i am sorry. pls tell me what you experieenced and let me know if you have any suggestion about how we can make it better (try to see the problem from the patient;s view. Patients, esp with OCD are often fearful about becoming dependent as well as being ill)
50 years old dirty, dishevelled patient has had at least one complaint about the office or staff on every visit. today complains that one of the vest nurses was fresh to her
i apologize, i will speak ti the nurse about that (do not blame the patient, no matter how provocative he or she is, for problems with office staff)
45 years old patient whose both parents died of CRC before 50 refuses to had colonoscopy because heard that the procedure is uncomfortable
“tell me more about your concerns related to the procedure”
identify the real reason for the refusal (fear that cancer will be found). DO NOT ATTEMPT TO FRIGHTEN THE PATIENT INTO ADHERING (eg. with photographs with untreated patients)
68 years old female insists on stopping a needed treatment (chemotherapy) because it is making her uncomfortable
“lets discuss ways that we can make the treatment more tolerate to you”
do not stop treatment before alternatives have been explored
a nurse tells the doctor that she saw a diabetes patient to put sugar in her coffee
“lets discuss your diet again”
do not become angry at noncompliant patient. This patient may need to be reminded of how to follow her diet
a patient believes (falsely) that his poor health behavior is actually beneficial to him
“tell me more about how you fell about your cigarette smoking” (Do not recommend methods of smoking cessation until the patient express willingness to try to stop
Without telling you what he is felling, a 54 hypertension patient asks the doctor to tell hime more about his illnes and side effect of the drugs
“tell me about the side effects you have been experiencing”
This patient may be reluctant to bring up embarrassing issues associated with the illness or treatment
A 5 years old girl needs to have a procedure that involves minor pain
“this will feel like a bug bite and it will stop hurting after count to five together”. The doctor should tell the child about how much pain she is likely to feel in a way that she will understand
The parents of a healthy 17 years old want the doctor to perform an abortion. the girs want to keep the baby whom tests have shown Down syndrome
Do not recommend a course of action, but do facilitate discussion about the options between the parents and the patient. The fact that baby has Down syndrome is irrelevant
25 years old request a 1st trimester abortion from a physician who has religious and morel prohibitions against abortions
“I do not perform abortions, but i will refer to a doctor who does”. Doctors are not required to perform any procedure a patient request. Do not be judgemental, do not impose your own beliefs on the patient and do not try to change her mind
An 82 years old has had 2 fall at home. She tells the doctor that her adult children are concerned and want her to go into a nursing home. She does not want to go
“let’s try to find out why you are falling”.
Then treat her medical problems and recommend environmental changes that allow her to stay safety at home as long as possible
A 76 male who is of different religion than you are, tells the doctor that he had a religious vision while praying and asks the doctor to pray with him
“that mast have been a very important moment for you”
Although the doctor does not have to pray with the patient, he should show support and understanding
A 60 dying patient asks thet doctor how long he has to live (3 months)
“While there have been exceptions, most people at this stage of the illness live about 3 months”
Be truthful and direct. Reassure the patient that you will not abandon him, but do not ofter philosophical or religious statements
Interviewing techniques - aim and technique per aim
- to establish support: a. support and empathy (interst and concern) b. validation (to give value and credits)
- to maximize information gathering a. facilitation (encourage to speak) b. reflection (encourage to elaborate an answer) c. silence
- to clarify information: a. confrontation (to call attention to inconsistencies in the patient response) b. recapitulation (to sum up informations)
psychiatric vs physical illness according to morbidity and mortality
much higer in psychiatric illness
the sick role - explain
a sick person asssumes a specific role in society and follows predictable behavioral patterns. These patterns include exemption from usual responsibilities, expectation of care by others, efforts toward getting better, and cooperation with health care personnel
Adherence - is NOT related to
patient’s gender, religion, socioeconomic or marital status, race, intelligence, education
factors that increase adherence
- good physician-patient relationship
- acute illness
- simple treatment schedule
- writen instruction
- short time in waiting room
- feeling ill and limitations of usual activities
- Recommending one behavioural change at a time
- beliefs that the benefits of care>time and money
- peer support
factors that decrease adherence
- cold and unapproachable physician
- few symptoms with little activity disruption
- verbal instriction (not written)
- chronic illness
- Complex treatment schedule
- long time at waiting room
- Recommend multiple behavioral changes per time
- Little peer support
- Beliefs that money, time >care benefits
Type A personality is characterized by
- time pressure
- competitiveness
- Coronary artery disease
Which patients are at greater risk for psychological reactions to illness, hospitalization, or surgery
- history of psychiatric illness
- if their relationship (family or medical staff) worsen
- -> fear can result in anger expression - ICU patiens
- Renal dialysis
- Surgical patients with unrealistic exptections for a procedure
