Patients' preferences concerning medical information and surrogacy: results of a prospective study in a French emergency department

Objective: To study the wishes of a sample of French patients about medical information and surrogacy, at a time when the French Ministry of Health is supporting increased patient autonomy.¶Design: A cohort of competent patients with non-critical illnesses or injuries completed an intention-to-act questionnaire on the amount of medical information they would want to receive should they be hospitalized or in a life-threatening situation. The percentage of patients who would want to have a surrogate if they were in a coma was determined, as well as the identity of the preferred surrogate. The subgroup of patients who were married or living with a partner was evaluated separately to determine how often the spouse/partner was the preferred surrogate. Associations were looked for between patients' wishes and age, sex, educational level, occupation, hierarchical order in the family, and level of confidence in medicine.¶Setting: The emergency room of a teaching hospital in the Paris area (France).¶Results: Of the 1089 patients included in the study, 5.5 % reported that they would not want any information, 25.3 % that they would want to participate actively in all decisions about their care, and 87.3 % that they would want to be fully informed if they were in a life-threatening situation. Slightly less than one-third of the patients (29.6 %) believed they would not want a surrogate if they developed a coma. Among the patients living with a spouse/partner, 40.6 % (229/561) indicated they would want their spouse/partner to be their surrogate. A significant correlation was observed between wanting more information and wanting a surrogate. Younger patients with a higher educational level were significantly more likely to predict a desire for information and for a surrogate than the other patients.¶Conclusion: Our patients expressed a strong desire to receive extensive information should they become seriously ill, and two-thirds of them reported they would want a surrogate. However, only 40.6 % of the patients living with a spouse/partner would want their spouse/partner to be their surrogate. These data suggest that the time has probably come to propose a nation-wide public hearing on medical information and surrogacy in France.     

The importance of appraisals

The annual appraisal is, for many veterinary staff, quite a nerve-racking experience. They may spend days worrying about it beforehand and afterwards thinking about all the things they should have said, or the things they did say that they now wished they hadn't! It's not uncommon to hear comments such as, “It's just a waste of time, nothing ever happens after my appraisal,” or “The CPD they promised never materialised,” from staff who are disillusioned about the appraisal system in their practice.     

Women living with AIDS and the Family Health Program professionals: disclosing the diagnosis

This qualitative study was carried out with women living with HIV/AIDS cared by a specialized STD/AIDS service and registered in a Family Health Program (FHP) unit. The purpose was to identify the motivations of women living with HIV/AIDS to provide private information to the FHP team. The study was performed using semi-structured interviews, analyzed with the bioethics theoretical framework. It was verified that women disclose the diagnosis to the FHP team when: the HIV/AIDS diagnosis was made in the unit; they feel there is better treatment for being HIV positive; they are bond as family members; there is trust; and women feel that they do not feel pity of them. Women so not disclose when: the professional's attitude produces fear and unreliability; they think that the FHP takes care of bedridden patients; they do not trust by fearing secret disclosure; and they already have all the care needed in the SCS.     

TOXIN-ANTITOXIN REACTION WITHOUT NEUTRALIZATION

1. Collodion particles adsorb diphtheria or tetanus or botulinus toxins. These toxins are retained on the particles when washed but are at least in part released in the animal. 2. The adsorbed toxins are neutralized by adsorption of the corresponding antitoxins but are unaffected by other serums. 3. When collodion particles are treated first with tetanus antitoxin, then with diphtheria toxin, they are not toxic, but they become toxic when they are treated first with diphtheria antitoxin, then with the diphtheria toxin. Similarly when collodion particles are treated first with diphtheria antitoxin and then with tetanus toxin, they do not become toxic, but they become toxic when they are treated with tetanus antitoxin and tetanus toxin.     

Development of the Miller Screening for Preschoolers

This paper describes the development and initial validation of the Miller Screening for Preschoolers (MSP). A pilot edition of the test was administered to 174 preschool children in the state of Colorado. Of these, 39 had been previously identified as developmentally delayed. On the basis of preliminary analyses, test items were discarded if they were insensitive to differences between the at-risk group and the not-at-risk group or if they were nonsignificantly related to developmental age trends; if they were only weakly related to the domain total score; if they were redundant with other items within a domain; if they were too easy or too difficult for any given age; if they were rated low by the testers on administration and scoring issues; or if the test materials were deemed to be too expensive. This paper presents final statistics for the selected screening test items and discusses implications for the design, construction, and validation of developmental tests.     

Evaluation of telenursing outcomes: satisfaction, self-care practices, and cost savings

Info-Santé CLSC, the Québec telenursing service, is a telephone health line nursing service that was implemented in 1995 in every local community service center (CLSC; n = 141) of 15 regional health authorities in the Province of Québec, Canada. It is, at present, one of the most important first-line health services and it operates in continuity with the other resources in the health and social service system. Info-Santé CLSC operates 24 hours a day, 7 days a week, and received more than 2,260,000 calls in 1997. This article will report the findings from the first province-wide survey of the service, based on a stratified random sample of 4,696 callers. The findings revealed that most respondents were highly satisfied with the service; they followed the nurses' advice and carried out self-care measures as recommended. Nursing interventions helped respondents feel self-reliant, like they could solve the same or similar problems should they occur in the future. The vast majority of respondents considered that the call they made to Info-Santé CLSC was useful in finding a solution to their problems. The vast majority also claimed that they would certainly call Info-Sante CLSC again should another problem occur. The majority reported they would have turned to another type of resource if Info-Santé CLSC had not existed; half of the respondents stated that they would have used emergency departments and a third would have consulted a doctor in private practice.     

The Medical School Years

Medical school can be very challenging, especially when students are considering applying to competitive specialties, like emergency medicine. Once medical students know that emergency medicine is the field they want to specialize in, a multitude of other questions arise, including how many EM rotations should they do? How can they shine during their EM rotations? When should they schedule their rotations, electives, and sub-internships? How can they get the strongest letters of recommendation? What are residency program directors looking for? Therefore, we are going to present in the Medical Student Forum section of the Journal of Emergency Medicine a series of six articles covering this and more.     

An innovative safe anesthesia and analgesia package for emergency pediatric procedures and surgeries when no anesthetist is available

Background

Adequate pain control through sedation and anesthesia for emergency procedures is a crucial aspect of pediatric emergency care. Resources for administering such anesthesia are extremely limited in many low-income settings.

Methods

Non-anesthetist providers in Western Kenya were trained in the use of a ketamine-based sedation and anesthesia package for non-anesthetists, Every Second Matters for Mothers and Babies-Ketamine? (ESM-Ketamine). Data on use and safety of this package for emergent and urgent pediatric procedures was collected. Providers were surveyed as to what they would have done for similar procedures if the ESM-Ketamine package were unavailable.

Results

Ninety procedures were completed for 77 pediatric patients utilizing the ESM-Ketamine package. Of these, 29 (32.2 %) cases were orthopedic reductions, 19 (21.1 %) were incision and drainage, and 19 (21.1 %) were debridement and irrigation of burns. Remaining cases included cesarean section, repair of perineal tear, foreign body removal, arthrocentesis, laceration repair, exploratory laparotomy, excision of mass, paracentesis, and circumcision. There were no serious adverse events in any of the cases, 17 % experienced minor adverse events including hypersalivation, hallucinations, or brief, self-resolving, oxygen desaturations. Providers were surveyed for 80 of the 90 cases as to what they would have done in the absence of the ESM-Ketamine package: in 26 cases (32.5 %), they reported they would proceed with the procedure without any anesthesia or analgesia; in 15 (18.75 %), they reported they would significantly delay the procedure while waiting for an anesthetist; in 13 (16.25 %), they reported they would attempt referral to another facility; and in 26 (32.5 %), they reported they would try using an alternate form of analgesia, primarily acetaminophen, ibuprofen, diclofenac, and/or diazepam. All surveyed providers reported they would use the ESM-Ketamine package again in similar cases.

Conclusions

The ESM-Ketamine package, through the use of a simplified protocol and checklist, allows for safe analgesia and anesthesia in children by non-anesthetists in a resource-limited setting for selected emergent and urgent procedures. This package addresses a significant gap in the availability of anesthesia services in low-income settings that would otherwise result in significant delays to procedures or proceeding with painful procedures with inadequate analgesia.

     

Anger and Locus of Control in Young Women with and without Premenstrual Syndrome

The purpose of this study was to examine differences in locus of control and anger in college women with and without premenstrual syndrome (PMS). One hundred thirty-seven female undergraduates completed a biographical questionnaire, the Rotter Internal-External Locus of Control (I-E) Scale, the Spielberger State Trait Anger Scale (STAS), the Framingham Anger Scale (FAS), and a women's health questionnaire. After 65 women who had had children or used hormonally based contraceptives or psychotropic medications were excluded, the remaining subjects were placed into a PMS (n = 48) or a non-PMS group (n = 24) according to whether they met DSM-IV criteria for Premenstrual Dysphoric Disorder (PMDD). After debriefing the sample, the women were asked if they believed they had PMS. Results of the study showed no significant differences between groups in locus of control or anger. Out of the 72 subjects in the final analysis, 64 (89%) believed they had PMS, and only 8 (or 11 %) believed they did not. Self-diagnosis was not always correct; 16 (22%) of the women who believed they had PMS did not meet the DSM-IV criteria for the disorder. The DSM-IV criteria may need further refinement and validation.     

Moral distress in carers for people with an intellectual disability who died during the COVID-19 pandemic,a template analysis extending the Barlem and Ramos model of moral distress

Background

This article aims to understand moral distress in carers of people with an intellectual disability during the COVID-19 pandemic.

Method

Nine staff carers of seven people with an intellectual disability, who had been participants of the IDS-TILDA study in Ireland, who died during the COVID-19 pandemic participated in in-depth, semi-structured telephone interviews. Template analysis was used to analyze the interviews.

Results

Obstructions in performing their duties left carers feeling powerless and experiencing moral conflict distress, moral constraint distress and moral uncertainty distress. Most managed to connect to the moral dimension in their work through peer support, understanding they fulfilled the wishes of the deceased, and/or thinking about how they or others did the best they could for the person they were caring for.

Conclusions

This research demonstrates that while restrictions may have been effective in reducing the spread of COVID-19, they were potentially damaging to carer wellbeing.     

Communicating Social Support to Grieving Clients: The Veterinarians' View

This exploratory study examines veterinarians' perceptions of how they offer social support to grieving clients. Because many clients cannot find the social support they would like from other sources when grieving the death of a pet, the role of the vet in offering support becomes increasingly important. The results indicate that vets perceive that they do offer social support; however, they have not been provided with training in how to do so. Limitations to the study and future directions are also discussed.     

How and what staff nurses learn about the medical devices they use in direct patient care

Registered nurses (N = 323) working in a 500-bed tertiary care hospital in a large midwestern city were surveyed to determine what and how they initially learned about the medical devices they use, and the consequences of their use. The most frequently identified methods of initial learning were trial and error (taught self) and reading the user instruction manual. At least 90% of respondents indicated that when they first learned about the device they learned how to operate it and its purpose and function. Medical device use causes more than 75% of staff nurses to feel stressed; 11% had used a medical device that had harmed a patient. ©1995 John Wiley & Sons, Inc.     

Use of natural health products in children: Experiences and attitudes of family physicians in Newfoundland and Labrador

Objective

To determine the experiences of family physicians in Newfoundland and Labrador with parents’ use of natural health products (NHPs) for their children and to assess physicians’ attitudes toward use of NHPs in children.

Design

A survey using the Dillman approach.

Setting

Newfoundland and Labrador.

Participants

All family physicians in the province.

Main outcome measures

Physician demographic characteristics; whether physicians inquire about the use of NHPs in children; the degree to which they think patients disclose use of NHPs in children; whether they counsel parents about the potential benefits or harms of NHPs; their own opinions about the usefulness of NHPs; whether they recommend NHPs in children and for what reasons; and the particular NHPs they have seen used in children and for what reasons.

Results

A total of 159 (33.1%) family physicians responded; 65.4% were men, 71.7% were Canadian medical graduates, and 46.5% practised in rural areas. Overall, 18.8% of family physicians said they regularly or frequently asked about NHP use; 24.7% counseled patients about potential harms. Only 1.9% of physicians believed NHPs were usually beneficial, but a similarly small number (8.4%) thought they were usually harmful. Most respondents were somewhat neutral; 59.7% said they never recommend NHPs for children, and a further 37.0% said they would only “sometimes” recommend NHPs.

Conclusion

Most physicians believed that NHPs were probably of little benefit but not likely to be harmful. Most NHPs used were vitamins and minerals. Physicians recognized that NHPs were often used by parents for children, but in general they believed NHPs had little effect on their day-to-day medical practices. Thirty-eight (24.7%) of the 154 physicians had at least once recommended an NHP (including vitamins) for their pediatric patients. Physicians believed that parents did not often disclose use of NHPs for their children, but at the same time physicians generally did not actively inquire.     

Wished for and avoided conversations with terminally ill individuals during final conversations

The current investigation examines retrospectively wished for and avoided conversations during the end of life with a deceased relational partner. Participants reported on conversations they wished they had engaged in and conversations that they intentionally avoided, as well as reasons why they did not engage in the conversations. Analyses revealed the following wished for and avoided conversations: negative relationship characteristics; death and dying; postdeath arrangements; and personal information. Furthermore, participants indicated the following reasons for not discussing the aforementioned topics during final conversations: emotional protection, relational differences, and condition of the dying. Theoretical and practical implications for end-of-life communication are discussed.     

Understanding mental illness: the experience of families of psychiatric patients

This qualitative study was designed to elicit the family's perspective of their experience of the first hospitalization of a relative. A major focus of the study was the process by which families developed an understanding of mental illness and its treatment. During unstructured interviews, seven families explained how they interpreted unfamiliar events and surroundings. They identified their needs and concerns related to their interpretation of 'mental illness', and they described their efforts to understand the patient from this perspective. The study identified processes by which families attached meaning to events: they reviewed past experiences and beliefs to make sense of the present experience; they examined their own behaviour as a contributor to the development of the illness; they observed and evaluated the hospitalization as treatment; and they asked questions about the future. The direction for nursing practice was identified in terms of providing support and information to families, as well as being aware of the emotional responses of families at all stages of the patient's illness.     

Palliative sedation and moral distress: A qualitative study of nurses

BackgroundClinical nursing practice may involve moral distress, which has been reported to occur frequently when nurses care for dying patients. Palliative sedation is a practice that is used to alleviate unbearable and refractory suffering in the last phase of life and has been linked to distress in nurses.AimThe aim of this study was to explore nurses' reports on the practice of palliative sedation focusing on their experiences with pressure, dilemmas and morally distressing situations.MethodsIn-depth interviews with 36 nurses working in hospital, nursing home or primary care.ResultsSeveral nurses described situations in which they felt that administration of palliative sedation was in the patient's best interest, but where they were constrained from taking action. Nurses also reported on situations where they experienced pressure to be actively involved in the provision of palliative sedation, while they felt this was not in the patient's best interest. The latter situation related to (1) starting palliative sedation when the nurse felt not all options to relieve suffering had been explored yet; (2) family requesting an increase of the sedation level where the nurse felt that this may involve unjustified hastening of death; (3) a decision by the physician to start palliative sedation where the patient had previously expressed an explicit wish for euthanasia.ConclusionsNurses experienced moral distress in situations where they were not able to act in what they believed is the patient's best interest. Situations involving moral distress require nurses to be well informed and able to adequately communicate with suffering patients, distressed family and physicians.     

Repressed and silent suffering: consequences of childhood sexual abuse for women’s health and well‐being

Scand J Caring Sci; 2013; 27; 422–432 Repressed and silent suffering: consequences of childhood sexual abuse for women’s health and well‐being Research results indicate that psychological trauma in childhood caused by child sexual abuse can have serious and widespread consequences for health and well‐being. The purpose of this study was to examine the consequences of childhood sexual abuse for women’s health and well‐being. The research methodology was phenomenology. Seven women with a history of childhood sexual abuse were interviewed twice with 1–6 months interval. For all the women, the abuse started when they were between 4 and 5. All of them were repeatedly violated and traumatized ever since then and were even still being victimized at the time of the interviews. The main result of the study is that time does not heal all wounds. All the women described great repressed and silent suffering in all aspects of life, and the abuse is still seriously affecting them and their loved ones. As children, they had learning problems, experienced bullying and had unexplained physical symptoms. In adulthood, they have been suffering multiple physical and psychological symptoms: five of them have fibromyalgia; all of them have been suffering chronic and widespread pain; they have all been dealing with depression and difficulty with close connections, and they all have trouble trusting others. Because they were kids, they have been using the health service to a great extent but without adequate help. It is important for health professionals to know the symptoms and consequences of childhood sexual abuse to be able to respond to adult survivors in a supportive and caring way. More effective therapeutic measures have to be developed to decrease their suffering.