Moral uncertainty: A case study of Covid-19

BackgroundMost writing about uncertainty in healthcare has addressed empirical uncertainty – that is, resulting from insufficient or conflicting facts.ObjectiveTo consider moral uncertainty by exploring how different theories apply to a single clinical case.MethodIn this philosophical reflection, I briefly acknowledge empirical uncertainty before introducing and exploring the topic of moral uncertainty – defined as the question of what to do when we do not know what (morally) to do—using a case study of my own mother’s deterioration and death from Covid-19.ResultsI identify and apply a number of philosophical theories relevant to managing moral uncertainty, including utilitarianism, deontology, practical rationality and feminist philosophy.ConclusionDifferent moral theories lead to different conclusions about the best course of action in situations of moral uncertainty.Practice implicationsDetailed analysis and close reading of a single case can provide insights into how to act in morally complex situations, but learning is in the form of enriched understanding, not formulaic rules.     

61例晚期胃癌病人疾病不确定感及应对方式探讨

目的:探讨晚期胃癌病人疾病不确定感及应对方式。方法:选取2016年1月—2018年12月医院收治的61例晚期胃癌病人,以中文版Mishel疾病不确定感量表(MUIS)、医学应对问卷(MCMQ)对病人疾病不确定感及应对方式进行评价,比较治疗前后MUIS、MCMQ各维度得分情况,并分析疾病不确定感与应对方式的关系。结果:61例晚期胃癌病人MUIS得分中不明确性维度得分最高,其次是复杂性、不可预测性、信息缺乏性维度得分;治疗后不明确性、复杂性、不可预测性、信息缺乏性维度得分均低于治疗前,差异具有统计学意义(P<0.05)。61例晚期胃癌病人治疗前MCMQ得分中“回避”维度得分最高,其次是“面对”“屈服”维度;治疗后“面对”维度得分最高,其次是“回避”“屈服”维度。治疗后“屈服”“回避”维度得分低于治疗前,“面对”维度得分高于治疗前,差异具有统计学意义(P<0.05)。“屈服”“回避”维度得分均与不明确性、复杂性、不可预测性、信息缺乏性维度得分呈正相关,“面对”维度得分与不明确性、复杂性、不可预测性、信息缺乏性维度得分呈负相关(P<0.05)。结论:晚期胃癌病人明确存在较高水平的疾病不确定感,其中“不明确性”维度得分最高,且治疗前主要应对方式为“回避”。疾病不确定感与应对方式可相互影响,屈服、回避可导致较高的疾病不确定感,而面对疾病是晚期胃癌病人积极的应对方式。     

移动平台在脑肿瘤患儿健康教育中的应用效果

目的:探讨移动平台在住院脑肿瘤患儿健康教育中的应用效果。方法:将118例脑肿瘤患儿及118名家属采用随机数字表法分为观察组及对照组。对照组由护士以口头宣教结合宣教单发放形式进行健康教育,观察组采用移动平台持续进行健康教育。比较两组患儿家属出院准备度得分及入院时、入院2周、出院时家属疾病不确定感得分情况。结果:观察组患儿家属出院准备度得分为(178.64±10.02)分,高于对照组的(156.71±9.00)分(P<0.05);出院时观察组患儿家属疾病不确定感得分为(58.31±4.45)分,低于对照组的(60.80±4.08)分(P<0.05)。结论:移动平台应用于脑肿瘤患儿健康教育中可明显改善患儿家属疾病不确定感,提高家属出院准备度水平,为后续患儿居家护理起到至关重要的作用。     

植入式心律转复除颤器手术前后患者确定感、焦虑与性格乐观状态的研究

目的研究比较植入式心律转复除颤器(ICD)作为心源性猝死的一级预防(primary prevention,PP)和二级预防(secondary prevention,SP),在植入前、植入后1周以及植入后1个月对患者情绪的不同影响。方法选择15例患者应用植入式心律转复除颤器作为心源性猝死的PP,15例患者应用植入式心律转复除颤器作为心源性猝死的SP,应用描述性横断面调查法,利用Mishel-疾病不确定感量表(Mishel’s Uncertainty in Illness Scale,MUIS-C),特质状态焦虑量表(State-Trait Anxiety Inventory,STAI)和生活目标量表(the Life Orientation Test,LOT-R),通过晤谈行半结构访问。结果在植入式心律转复除颤器植入前,两组患者的MUIS-C分值都较高(PP=67.67±13.36;SP=70.27±6.80,P=0.507);LOT-R分值为PP=15.67±3.8,SP=16.47±3.6,P=0.557;STAI分值为PP=37.40±10.0,SP=37.73±13.6,P=0.940。在植入式心律转复除颤器植入后1个月,PP患者的MUIS-C分值明显低于SP患者(PP=62.33±4.17,SP=67.87±4.61,P=0.002)。结论利用植入式心律转复除颤器作为SP的患者护理时更应该引起护士的重视。     

Robust H∞ performance analysis for uncertain discrete‐time singular systems with time‐varying delays

This paper considers the problem of robust H∞ performance analysis for uncertain discrete‐time singular systems with time‐varying delays. Firstly, a delay‐dependent stability criterion under the H∞ performance index for the systems is given based on constructing a generalized Lyapunov–Krasovskii function and introducing a new difference inequality. Then, a sufficient condition ensuing the system to be regular, causal as well as stable for all admissible uncertainties is proposed in terms of a set of strict linear matrix inequalities (LMIs). Finally, we provide examples to show the reduced conservatism and effectiveness of the proposed conditions. Copyright © 2014 John Wiley & Sons, Ltd.     

颅脑手术患者家属疾病不确定感与应对方式的调查分析

目的分析颅脑手术患者家属的疾病不确定感和应对方式水平,分析两者之间的关系。方法采用一般资料调查表、Mishel疾病不确定感家属量表和简易应对方式问卷对便利抽取的200名家属进行调查。结果家属疾病不确定感总分为(96.72±10.36)分,计算条目平均分后发现,得分最高的是"不明确性",其次是"不可预测性"、"信息缺乏"和"复杂性"。家属的应对方式、积极应对分量表和消极应对分量表的条目平均分分别为(1.62±0.48)分、(1.86±0.82)分、(1.25±0.51)分。疾病不确定感总分及各维度得分均与积极应对呈负相关,复杂性维度和信息缺乏维度与消极应对呈正相关。结论颅脑手术患者家属的疾病不确定感水平较高,应对方式水平有待进一步提高,积极的应对方式可以降低其疾病不确定感。     

Watchful waiting: role of disease progression on uncertainty and depressive symptoms in patients with chronic Hepatitis C

Background and Aims: New therapies for HCV are rapidly emerging and providers are advising select patients to defer treatment and elect ‘watchful waiting’. During the watchful waiting period, patients have been shown to have high rates of illness uncertainty and depression. We sought to answer the question of whether reassuring histological data (showing minimal fibrosis or no fibrosis progression over time) is associated with less illness uncertainty and depressive symptoms. Methods: This was a single‐centre outpatient prospective cohort study to determine whether stage of fibrosis, fibrosis progression and reasons for treatment deferral were related to illness uncertainty and depressive symptoms in patients following watchful waiting. Results: Illness uncertainty was significantly related to depressive symptoms (r = 0.49, P < 0.01). More than half of the participants (54%) had moderate levels of uncertainty. About 40% of the participants were at risk for clinical depression (21.7% at mild to moderate risk and 18.5% at high risk). Treatment naïve subjects had lower mean scores on both the CES‐D (depressive symptoms measure) and the MUIS‐A (illness uncertainty measure) total score, MUIS‐A Ambiguity subscale and MUIS‐A Inconsistency subscale than subjects who failed treatment or were interferon intolerant or ineligible. Surprisingly, liver fibrosis stage and progression were not significantly associated with overall illness uncertainty or depressive symptoms. Conclusion: Patients with chronic hepatitis C on watchful waiting are at high risk for significant illness uncertainty and depressive symptoms. Reassuring histological data does not seem to correlate with less uncertainty or depressive symptoms.     

Examining the variation in GPs’ referral practice: a cross-sectional study of GPs’ reasons for referral

Background

There is a large variation in referral rates to secondary care among GPs, which is partly unexplained.

Aim

To explore associations between reasons for referral to secondary care and patient, GP, and healthcare characteristics.

Design and setting

A cross-sectional study in Northern Norway.

Method

Data were derived from 44 (42%) of 104 randomly selected GPs between 2008 and 2010. GPs scored the relevance of nine predefined reasons for 595 referrals from 4350 consecutive consultations on a four-level categorical scale. Associations were examined by multivariable ordered and multivariable multilevel logistic regression analyses.

Results

Medical necessity was assessed as a relevant reason in 93% of the referrals, 43.7% by patient preference, 27.5% to avoid overlooking anything, and 14.6% to reassure the patient. The higher the referral rates, the more frequently the GPs referred to avoid overlooking anything. Female GPs referred to reassure the patient and due to perceived deficient medical knowledge significantly more often than male GPs. However, perceived easy accessibility of specialists was significantly less frequently given as a reason for referral by female GPs compared with male GPs. When the GPs scored the referrals to be of lesser medical necessity, male GPs referred significantly more frequently than female GPs to reassure the patient due to patient preference and perceived deficient medical knowledge.

Conclusion

There are striking differences in reasons for referral between Norwegian male and female GPs and between GPs with high and low referral rates, which reflects difficulties in handling professional uncertainty. Referring to reassure the patients, especially when referrals are less medically necessary, may reflect consideration and acquiescence towards the patients.