Determining the validity of advance directives

We examine the ethical principles underpinning advance directives (ADs) and the legal duties of doctors in determining their validity. A physician attending an incompetent patient with an acute life-threatening illness, and an AD refusing treatment, should ensure that the AD is legally valid before making the treatment decision. Treatment against a patient's wishes, as expressed in a valid AD, compromises patient autonomy and may constitute battery. Conversely, withholding treatment in accordance with an AD that is not legally valid risks substantial harm to the patient and may constitute breach of the duty of care and negligence. Legally valid directives should be respected. If an AD is not legally valid, the patient should be treated in his or her best interests. If uncertain, the physician should treat according to the patient's best interests while seeking legal advice.     

Advance directives in psychiatric care: a narrative approach

Advance directives for psychiatric care are the subject of debate in a number of Western societies. By using psychiatric advance directives (or so-called "Ulysses contracts"), it would be possible for mentally ill persons who are competent and with their disease in remission, and who want timely intervention in case of future mental crisis, to give prior authorisation to treatment at a later time when they are incompetent, have become non-compliant, and are refusing care. Thus the devastating consequences of recurrent psychosis could be minimised. Ulysses contracts raise a number of ethical questions. In this article the central issues of concern and debate are discussed from a narrative perspective. Ulysses contracts are viewed as elements of an ongoing narrative in which patient and doctor try to make sense of and get a hold on the recurrent crises inherent in the patient's psychiatric condition.     

甘肃省农村地区精神疾病患者生存状况的田野调查

目的了解甘肃省农村地区精神疾病患者的生存现状。方法采用个案研究法和访谈法,以甘肃省景泰县的3个乡镇为田野工作点,对甘肃省农村地区精神疾病患者的生存状况进行田野调查。结果农村精神疾病患者家庭经济困难,无力承担高昂的治疗费用,多采用封建迷信的方法或服用偏方进行治疗;不少农村精神疾病患者被长年关在家中或被家属诱骗到外地抛弃,任其四处流浪;愚昧无知和讳疾忌医,使很多农村精神疾病患者的病情不能及时发现、及早治疗;对精神疾病患者及其家庭的歧视,使得农村精神疾病患者难以回归社会。结论农村地区精神疾病患者的生存状况不容乐观,需要全社会的共同关注与推动才能妥善地解决。     

Management of unstable angina. Guidelines--2000

Consulting the family of an incompetent patient is necessary in order to ensure that you take into account (a) any information that is known about what the patient would have wanted; (b) any signs as to what the patient wants now; (c) the capacity of the family and/or nursing home to look after the patient; and (d) the views of the family and primary caregivers on the appropriateness of various forms of treatment and care. Futile or overly burdensome treatment should not be administered. Social prejudices against elderly and/or demented people may unjustly deny them appropriate medical and nursing care. The ethical challenges facing families/caregivers of incompetent patients should be framed in ways that genuinely help them to come to reasonable solutions.     

Variability in physicians' decisions on caring for chronically ill elderly patients: an international study.

OBJECTIVES: To determine what treatment decisions physicians will make when faced with an incompetent elderly patient with life-threatening gastrointestinal bleeding and to identify the factors that affect their decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. OUTCOME MEASURE: A self-administered questionnaire containing three case vignettes. Each provided the same details on an incompetent elderly patient; however, one gave no information about the wishes of the patient and his family (no directive), the second provided a do-not-resuscitate (DNR) request, and the third included a detailed therapeutic and resuscitative effort chart (DTREC) requesting maximum therapeutic care without admission to the intensive care unit (ICU). The four treatment options were supportive care only, limited therapeutic care, maximum therapeutic care without admission to the ICU and maximum care with admission to the ICU. MAIN RESULTS: Treatment decisions varied and were systematically related to age, level of training and country (p less than 0.001). The older physicians and those in family medicine were less likely than the others to choose aggressive treatment options. Brazilian and US physicians were the most aggressive; Australian physicians were the most conservative. The DNR request resulted in a significant decrease in the number of physicians choosing aggressive options (p less than 0.001). The DTREC resulted in a move toward more aggressive treatment, as outlined in the directive (p less than 0.001). Overall, however, about 40% of the physicians chose a level of care different from what had been requested. Furthermore, over 10% would have tried cardiopulmonary resuscitation despite the DNR request. CONCLUSION: Treatment of incompetent elderly patients with life-threatening illness varies widely within and between countries. Uniform standards should be developed on the basis of societal values and be communicated to physicians.     

Gardner; re BWV: Victorian Supreme Court makes landmark Australian ruling on tube feeding

The Victorian Supreme Court has decided that artificial nutrition and hydration provided through a percutaneous gastrostomy tube to a woman in a persistent vegetative state may be withdrawn. The judge ruled, in line with a substantial body of international medical, ethical and legal opinion, that any form of artificial nutrition and hydration is a medical procedure, not part of palliative care, and that it is a procedure to sustain life, not to manage the dying process. Thus, the law does not impose a rigid obligation to administer artificial nutrition or hydration to people who are dying, without due regard to their clinical condition. The definition of key terms such as "medical treatment", "palliative care", and "reasonable provision of food and water" in this case will serve as guidance for end-of-life decisions in other states and territories. The case also reiterates the right of patients, and, when incompetent, their validly appointed agents or guardians, to refuse medical treatment. Where an incompetent patient has not executed a binding advance directive and no agent or guardian has been appointed, physicians, in consultation with the family, may decide to withdraw medical treatment, including artificial nutrition or hydration, on the basis that continuation of treatment is inappropriate and not in the patient's best interests. However, Victoria and other jurisdictions would benefit from clarification of this area of the law.     

Recognition and evaluation of delirium

Delirium (acute confusional state) is one of the most common mental disorders encountered in patients with medical illness, particularly among those who are older. It is associated with many complex underlying medical conditions and can be hard to recognise. Systematic studies and clinical trials are difficult to perform in patients with cognitive impairment; recommendations for evaluating and treating delirium are based primarily upon clinical observation and expert opinion. Our knowledge of the clinical epidemiology of delirium has substantially increased in the last decade, providing a basic framework for understanding and managing the disorder.     

患者对电子简要病历和“健康空间”的态度：定性研究

目的 证明患者和公众对电子简要病历（SCR,由全科医生记录并汇集成中心存储医疗资料）和“健康空间”（个人的健康组织者,让人们通过互联网就能够查看他们的病历）的观点,特别关注那些健康知识少、社会地位被潜在歧视或很难得到医疗保健的人群。 设计 103半结构式个人访谈和7个专题小组访谈。 背景 英国3个早期托管初级医疗保健的信托集团正在对病历和“健康空间”进行试验。所有的试验都在社会经济相对较差的地区进行。 参与者 个人访谈的参与者都是从外科全科医生、未预约中心、下班时间中心和急诊科募集而来。专题小组的参与者征集于志愿机构;他们包括弱势群体的支持者和英语水平有限人群的支持者;艾滋病患者;精神健康服务的使用者;年轻人;老年人和成瘾药物康复计划的参与者。 方法 在不同的情况下,询问参与者是否得到过有关简要病历和“健康空间”的信息和他们对共享电子病历的观点。 结果 大部分人不知道电子简要病历或“健康空间”,没有回想起接受过有关信息。他们看到了持有简要病历的好处和缺点,认为是个人选择时前后对照的权衡过程。这种选择的关键影响因素包括任何一种疾病的特征（尤其是否可能需要急诊）;过去和现在医疗保健的经历和政府的监督;个人的参与程度和健康知识;他们对初级医疗保健队伍和广泛的英国国家卫生服务体系（NHS）的信任和信心。总的来说,患有被歧视疾病的人们对于简要病历更肯定,而声称是代表“弱势群体”讲话的人们对简要病历不那么肯定。人们普遍误解病历,尤其是混淆病历中包含什么数据和谁有权使用它。大部分人对他们的医疗数据记录或通过“健康空间”使用他们的病历不感兴趣。但是,有一些人看到了这项新技术的潜力在于支持自我管理和对慢性疾病的非专业保健。 结论 这是一项早期托管地点扩展信息化项目,但公众对当前共享电子病历记录的政策仍然不清楚,虽然大部分人认为这是一种进步。对于创建和访问个人的病历记录表示“暗示赞成”的模式需再次评估,或许在访问个人病历记录时更适合采用“同意查看”。     

Compulsory detention in hospital under the Mental Health Act 1983

Presented here are sections of England's and Wales' Mental Health Act 1983 that relate to the compulsory admission to a hospital of patients suffering from a mental disorder, together with a diagrammatic representation of how they should be used in decision making. These excerpts address the definition of mental disorder; the purpose and duration of detention; the grounds for admission; who may make the application; and which health professionals are required to make the medical recommendation. The Mental Health Act provides no authority for third party consent to treatment of patients without mental disorder who refuse treatment or for treatment of medical conditions unless the condition is causing mental disorder.     

The right to be allowed to die.

The unbridled use of modern medical skills and technology in preserving life at all costs has stimulated interest in expressing a 'right to die' by the legally competent patient who is anxious to protect his autonomy. Some recent decisions by American courts are seen to threaten this 'right to die' of competent patients and imply that legally incompetent patients including children should not have this right under any circumstances, even when expressed on their behalf by guardians, nearest relatives or parents. It is argued that this is contrary to 'natural justice' as viewed by most people. It should be possible to develop procedures which are protective of the basic 'right to life' of the incompetent yet will recognise circumstances where they could be allowed to die. This paper was presented at the 1983 annual conference of the London Medical Group, 'Human Rights in Medicine'.     

做好满意度调查 进一步提升服务质量

目的通过满意度调查使医务人员从单纯的疾病诊疗转变为＂以病人为中心＂的身心治疗;从单一注重患者的治疗转变为以注重患者的感受为中心,使患者的满意度上升,充实＂以人为本＂的全面诊治和心理治疗。方法采取住院患者满意度调查,每日1次,对医生行为、护理技术、服务态度等进行调查。结果患者满意度由过去的72.95%上升到92.80%,达到了预期效果。结论满意度调查可以约束医务人员的不良行为,增强医务人员主动服务的意识,提高临床医疗服务质量。     

Assessing competence to refuse medical treatment.

Doctors have a duty to ensure that patients in their care who refuse medical treatment are competent to do so. Doctors who comply with an incompetent patient's refusal of treatment risk harm to the patient and are breaching their duty of care. On the other hand, doctors who treat a competent patient against the patient's will violate his or her autonomy and commit a battery. The test of competence is a legal one, with the courts being the final arbiters in cases of doubt. Assessment of competence involves a three-step process of determining whether the patient (a) can comprehend and retain relevant information, (b) believes the information, and (c) can weigh the information in the balance and arrive at a choice. Asking patients a few simple questions can help doctors assess their competence.     

What people close to death say about euthanasia and assisted suicide: a qualitative study

OBJECTIVE: To explore the experiences of people with a "terminal illness", focusing on the patients' perspective of euthanasia and assisted suicide. METHOD: A qualitative study using narrative interviews was conducted throughout the UK. The views of the 18 people who discussed euthanasia and assisted suicide were explored. These were drawn from a maximum variation sample, who said that they had a "terminal" illness, malignant or non-malignant. RESULTS: That UK law should be changed to allow assisted suicide or voluntary euthanasia was felt strongly by most people. Those who had seen others die were particularly convinced that this should be a right. Some had multiple reasons, including pain and anticipated pain, fear of indignity, loss of control and cognitive impairment. Those who did not want to be a burden also had other reasons for wanting euthanasia. Suicide was contemplated by a few, who would have preferred a change in the law to allow them to end their lives with medical help and in the company of family or friends. The few who opposed a change in UK law, or who felt ambivalent, focused on involuntary euthanasia, cited religious reasons or worried that new legislation might be open to abuse. CONCLUSION: Qualitative research conducted on people who know they are nearing death is an important addition to the international debate on euthanasia and assisted suicide. Those who had seen others die were particularly convinced that the law should be changed to allow assisted death.     

Issues of consent and the primary-school medical

This article discusses what level of consent is needed from a child or parent before a primary-school medical can take place (i.e. where children are aged under 12). It also considers whether there are occasions when a doctor can see a child if the parents have failed to give consent or have explicitly refused consent. Primary-school children are considered incompetent to make decisions about their own medical treatment and so their consent does not need to be gained before a medical takes place, although it is highly desirable to obtain it. However, a doctor cannot justify a decision to see a child purely in terms of the benefit conferred on the child. Parents can be wronged if their wishes are ignored and usually those wishes should be considered overriding. Normally, general consent, which need not be fully informed, is needed before a school medical. However, if a child is considered to be in danger of being harmed significantly or suspected to have a major medical condition, a medical should go ahead regardless of the level of consent obtained from the parent, so that a reasonable standard of health is maintained for the child.     

对我国精神病判定操作过程的伦理思考

通过对精神病判定过程和送治、收治行为的分析,提出要尽快为精神卫生立法,规范判断过程。避免正常人因判定操作的模糊性而被乱贴标签强制收治,防止犯罪分子假借法律对实施犯罪行为的精神病人的量刑规定来逃脱法律制裁,同时尊重和捍卫真正精神病患者的权利。     

A cost comparison of traditional and orthodox mental health care

This study examines whether cost is a factor in determining the choice of therapy in patients with mental illness. The focus therefore is to compare the cost of therapy (and not scientific basis or efficacy of treatment), in the short term, of traditional with orthodox mental health care. Sixty patients comprising 23 and 28 patients receiving therapies at orthodox and traditional psychiatric facilities respectively were interviewed. Information was obtained in the areas of sociodemographic data, duration of illness before presentation, duration of therapy, costs of consultation, medication, accommodation and feeding among others. It was found that traditional mental health care, in the short run, was three times more expensive than orthodox mental health care. Future health campaign programs should emphasize the fact that traditional mental health care is not just less effective, but costlier than orthodox mental health care. This might further discourage people from patronizing traditional mental health practitioners.     

Problems in deceptive medical procedures: an ethical and legal analysis of the administration of placebos

The use of placebos in therapy or research poses ethical questions. What are the benefits and the costs in ethical terms of condoning deception of the patient or subject? What does the deception mean for the patient''s or subject''s right to give informed consent to his treatment?Doctors are rightly expected to disclose to their patient facts which would in their judgement best enable him to give informed consent to treatment. On occasion, the degree of this disclosure may be limited by the need to avoid hazarding the success of treatment of an unstable patient whose condition threatens his life, but doctors should have no right to withhold information just to prevent a patient refusing consent to therapy. No such limitation should apply in experiments where full disclosure must operate to enable the subject to give his informed consent.The potential medical benefits for the patient of placebo therapy have to be weighed against all the ethical costs of the deception and dishonesty involved, including the longer term repercussions on doctor/patient trust: similar ethical costs may arise in experiments involving the use of placebos without disclosure of this as a possibility to the subject. Deception is ethically degrading to both parties not only being a breach of trust, but denying the moral autonomy of the patient or subject to make his own choice.The writer concludes that placebos should be used only with full disclosure and consent whether in therapy or in research, and that this need not impede the success of either.     

癌症晚期／生命有限患者的姑息性镇静治疗（四）

间隙性姑息性镇静治疗的主要目的是让生命的危象恢复平静,然后允许患者恢复意识。姑息性镇静治疗是常规的临床治疗方法,要与有意终止生命的行为明确地区分;姑息关怀包含了使患者家属感觉舒服和对家属的支持,家属在作姑息性镇静治疗的决定和整个镇静治疗中起着重要的作用;一旦作出镇静治疗的决定,就要进一步考虑镇静程序等。     

The cost of refusing treatment and equality of outcome.

Patients have a right to refuse medical treatment. But what should happen after a patient has refused recommended treatment? In many cases, patients receive alternative forms of treatment. These forms of care may be less cost-effective. Does respect for autonomy extend to providing these alternatives? How for does justice constrain autonomy? I begin by providing three arguments that such alternatives should not be offered to those who refuse treatment. I argue that the best argument which refusers can appeal to is based on the egalitarian principle of equality of outcome. However, this principle does not ultimately support a right to less cost-effective alternatives. I focus on Jehovah''s Witnesses refusing blood and requesting alternative treatments. However, the point applies to many patients who refuse cost-effective medical care.     

建立我国AID双向医患关系伦理规范模式初探

探讨了建立AID双向医患关系伦理规范模式的必要性，该模式的社会主义伦理基础并具体描述了该模式的主要内容和实现程序，它是确定以患者为中心的医疗宗旨和医患之间相互尊重、地位权利平等、整体关怀、综合治疗伦理原则为基础的，并将该伦理原则贯穿于AID咨询、诊断、方案制订、手术到术后随访等各阶段或全过程医患双向作用的行为规范模式的有机统一体。