The worried young adult as a primary care patient

BACKGROUND: Being worried about one's complaint is common among primary health care patients. Persistent and intensive worry may, however, have negative consequences. OBJECTIVES: We explored complaint-related worry and factors associated with it among 18- to 39-year-old primary health care patients. METHODS: Sixty-two patients evaluated the intensity of their worry and the severity of their complaint before seeing their GP. They were also interviewed about their background and filled in questionnaires about general tendency to illness-related worry and psychiatric symptoms. RESULTS: The intensity of worry varied greatly. One fourth of the patients reported intense worry. A general tendency to worry about health and hostile reactions were associated with both the intensity of worry and the severity appraisals. The patient's education and the duration and perceived course of the complaint also played a role in worrying and in the perceptions of the severity of the complaint. CONCLUSIONS: Some psychological characteristics may dispose patients to intensive worrying and pessimistic appraisals of their complaint. This challenges the GP to pay attention to the patients' perspectives and knowledge. Careful elucidation of the patients' experiences of their complaints is especially indicated in the case of complaints of long duration and a stable course.     

Pregnant and mentally incompetent

Two women, aged 31 and 36 years, under treatment for schizophrenia and psychotic episodes, respectively, became pregnant and decided to discontinue their medication. Thereupon the psychiatric disorder recurred and they refused--i.e. they were unable--to consent to a proposed treatment or investigation regarding their pregnancies. The necessary consent had to be obtained from a legal guardian. This was the husband in the first, urgent case. In the second case approval from the judge was obtained for the patient to be admitted against her will to protect her life and that of the foetus. In the Netherlands obstetric intervention to protect the life of the mother or her unborn child is legally regulated by the Wet Bijzondere Opnemingen in Psychiatrische Ziekenhuizen (Act on Compulsory Admissions to Psychiatric Hospitals) and the Wet op de Geneeskundige Behandelingsovereenkomst (Act on Agreement Concerning Medical Treatment).     

Design considerations for adult patient education

A variety of factors require attention in the design of patient education programs for adults. Andragogy, the art and science of helping adults learn, describes certain conditions of learning that are more conducive to growth and development for adults and prescribes practices in the learning-teaching transaction to meet them. Stigma, a special discrepancy between virtual and actual social identity, reduces a patient's self-esteem and fosters a feeling of dependence on others for care. Anxiety related to diagnosis and illness creates a situation in which patients cannot productively learn. The stages in acceptance of diagnosis provide a roadmap for understanding a patient's feelings/psychological processes and insight into opportunities to intervene with patient education. The specific disease a patient has effects his ability to learn. Each of these factors is considered with implications described for designing and implementing patient education activities for adults.     

Design considerations for adult patient education

A variety of factors require attention in the design of patient education programs for adults. Andragogy, the art and science of helping adults learn, describes certain conditions of learning that are more conducive to growth and development for adults and prescribes practices in the learning-teaching transaction to meet them. Stigma, a special discrepancy between virtual and actual social identity, reduces a patient's self-esteem and fosters a feeling of dependence on others for care. Anxiety related to diagnosis and illness creates a situation in which patients cannot productively learn. The stages in acceptance of diagnosis provide a roadmap for understanding a patient's feelings/psychological processes and insight into opportunities to intervene with patient education. The specific disease a patient has effects his ability to learn. Each of these factors is considered with implications described for designing and implementing patient education activities for adults.     

The young adult chronic psychiatric patient in an era of deinstitutionalization

Assessments of the consequences of deinstitutionalization tend to focus primarily on observable changes in psychiatric services. Equally critical, and less often noted, are changes in the target population of deinstitutionalization that have accrued as the result of new service initiatives and changing loci of care. Young adult chronic psychiatric patients, a newly emerging service entity, throw into bold relief the problems associated with delivering care to a changing patient population.     

Informed consent and incompetent medical patients

The mentally incapacitated patient is frequently encountered in the general medical hospital. Incapacity is the clinical state in which a patient is unable to participate in a meaningful way in medical decisions. Mentally incapacitated patients relinquish the authority, that is the competent patient's right, to choose among professionally acceptable alternative treatments. Such patients, therefore, require a surrogate decision-maker. There are certain clinical situations in which questions of incapacity are especially important to consider. In a study for the President's Commission for the Study of Ethical Problems in Medical Biomedical and Behavioral Research, the most common problem in recognizing incapacity was found with previously capable patients who became transiently incapacitated during the course of hospitalization. Questions of incapacity or the authority of surrogate decision-makers also arose with comatose, mentally retarded, mentally ill, and physically handicapped patients. While standards to determine capacity remain unclear, a practical approach is to demonstrate that a patient is able to describe the physician's view of the situation and to understand the physician's opinion as to the best intervention. When a patient is deemed to be incapacitated, the physician should turn to family members, whenever possible, to make decisions.     

Court's guidelines on incompetent patients compromise their rights

All patients have the right to request or to forego extraordinary means. Who shall make this decision for incompetent patients? A Massachusetts court, ruling that only a court is competent to decide such requests, contradicts theologians' recommendations. These decisions should be left to the patients' closest relatives with the help of the physician.