Ready and willing? Physicians' sense of preparedness for bioterrorism.
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Little is known about contemporary physicians' sense of preparedness for bioterrorism, willingness to treat patients despite personal risk, or belief in the professional duty to treat during epidemics. In a recent national survey few physicians reported that they or their practice are "well prepared" for bioterrorism. Still, most respondents reported that they would continue to care for patients in the event of an outbreak of "an unknown but potentially deadly illness," although only a narrow majority reported believing in a professional duty to treat patients in epidemics. Preparing physicians for bioterrorism should entail providing practical knowledge, preventive steps to minimize risk, and reinforcement of the profession's ethical duty to treat. (+info)
Results from a prospective, randomized, controlled study evaluating the acceptability and effects of routine pre-IVF counselling.
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BACKGROUND: The aim of this study was to evaluate a model of routine pre-IVF counselling focusing on the narrative capacities of couples. The acceptability of counselling, the effects on emotional factors and the participants' assessments were considered. METHODS: The study included 141 consecutive childless couples preparing for their first IVF. Randomization was carried out through sealed envelopes attributing participants to counselled and non-counselled groups and was accepted by 100 couples. Another 12 couples refused randomization because they wanted counselling and 29 because they did not. Questionnaires including the State-Trait Anxiety Inventory, the Beck Depression Inventory and assessments of help were mailed to couples before IVF and counselling, and after the IVF outcome. RESULTS: Counselling was accepted by 79% (112/141) of couples. There was no significant effect of counselling on anxiety and depression scores which were within normal ranges at both times. Counselling provided help for 86% (75/87) of initially non-demanding subjects and 96% (25/26) of those initially requesting a session. Help was noted in areas of psychological assistance, technical explanations and discussing relationships. CONCLUSIONS: This model of routine counselling centred on the narrative provides an acceptable form of psychological assistance for pre-IVF couples. (+info)
Breaking up is never easy: GPs' accounts of removing patients from their lists.
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OBJECTIVE: The aim of this study was to understand why GPs choose to end their relationship with patients by removing them from their lists. METHODS: Semi-structured interviews were carried out with 25 GPs from 22 general practices in Leicestershire. Qualitative analysis was performed using the constant comparative method. The main outcome measures were participants' accounts of removing patients from their lists. RESULTS: GPs use removal as a means of ending their professional relationships with problematic patients. All of the doctors indicated that they wished to retain the right to remove patients and stressed that removal is a rare event which they only use as a "last resort". There are two distinct but overlapping types of patients who are most likely to become eligible for removal: "bad" patients, who break the rules of the doctor-patient or practice-patient relationship, and "difficult" patients, with whom the doctor-patient relationship is so strained that doctors feel they can no longer care for them. The doctors may choose to remove a patient without warning or else to write a short letter giving "relationship breakdown" as the reason. They find it hard to confront the patient openly about the difficulties in the relationship. CONCLUSIONS: The ability to remove patients is a right that GPs value. They report that it is rare for them to seek to end their relationships with patients and, when they do, it is for reasons that are important in the maintenance of professional boundaries or fulfilling professional responsibilities. (+info)
Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database.
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Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PortoPH) are pulmonary vascular consequences of advanced liver disease associated with significant mortality after orthotopic liver transplantation (OLT). Data from 10 liver transplant centers were collected from 1996 to 2001 that characterized the outcome of patients with either HPS (n = 40) or PortoPH (n = 66) referred for OLT. Key variables (PaO2 for HPS, mean pulmonary artery pressure [MPAP], pulmonary vascular resistance [PVR], and cardiac output [CO] for PortoPH) were analyzed with respect to 3 definitive outcomes (those denied OLT, transplant hospitalization survivors, and transplant hospitalization nonsurvivors). OLT was denied in 8 of 40 patients (20%) with HPS and 30 of 66 patients (45%) with PortoPH. Patients with HPS who were denied OLT had significantly worse PaO2 compared with patients who underwent transplantation (47 vs. 52 mm Hg, P <.005). Transplant hospitalization survival was associated with higher pre-OLT PaO2 (55 vs. 37 mm Hg; P <.005). MPAP was significantly higher (53 vs. 45 mm Hg; P <.015) and PVR was significantly worse (614 vs. 335 dynes. s. cm(-5); P <.05) in patients with PortoPH who were denied OLT compared with patients who underwent transplantation. Transplant hospitalization mortality was 16% (5/32) in patients with HPS and 36% (13/36) in patients with PortoPH. All of the deaths in patients with PortoPH occurred within 18 days of OLT; 5 of the 13 deaths in patients with PortoPH occurred intraoperatively. We concluded that patients with HPS (based on a combination of low PaO2 and nonpulmonary factors) and patients with PortoPH (based on pulmonary hemodynamics) were frequently denied OLT because of pre-OLT test results and comorbidities. For patients who subsequently underwent OLT, transplant hospitalization mortality remained significant for both those with HPS (16%) and PortoPH (36%). (+info)
Survival of very preterm infants: Epipage, a population based cohort study.
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OBJECTIVE: To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital. DESIGN: A prospective observational population based study. SETTING: Nine regions of France in 1997. PATIENTS: All births or late terminations of pregnancy for fetal or maternal reasons between 22 and 32 weeks gestation. MAIN OUTCOME MEASURE: Life status: stillbirth, live birth, death in delivery room, death in intensive care, decision to limit intensive care, survival to discharge. RESULTS: A total of 722 late terminations, 772 stillbirths, and 2901 live births were recorded. The incidence of very preterm births was 1.3 per 100 live births and stillbirths. The survival rate for births between 22 and 32 weeks was 67% of all births (including stillbirths), 85% of live births, and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age: 31% of all infants born alive at 24 weeks survived to discharge, 78% at 28 weeks, and 97% at 32 weeks. Survival among live births was lower for small for gestational age infants, multiple births, and boys. Overall, 50% of deaths after birth followed decisions to withhold or withdraw intensive care: 66% of deaths in the delivery room, decreasing with increasing gestational age; 44% of deaths in the neonatal intensive care unit, with little variation with gestational age. CONCLUSION: Among very preterm babies, chances of survival varies greatly according to the length of gestation. At all gestational ages, a large proportion of deaths are associated with a decision to limit intensive care. (+info)
Engaging the reluctant GP in care of the opiate misuser: Pilot study of change-orientated reflective listening (CORL).
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BACKGROUND: The GP is central to plans for improved general health care and increased availability and delivery of addiction treatment to drug misusers in the UK. Attention to the actual quality of overall primary care, rather than just the treatment of dependence, has, however, been limited. OBJECTIVES: The purpose of this study was to test the feasibility of delivery and potential value of a brief motivational enhancement intervention targeting the quality of primary care given to opiate misusers by GPs. METHOD: This study had an observational 'before and after' design with follow-up assessment after 2-3 months. The target population was all GPs in two Primary Care Groups who had neither attended training events nor were involved in the treatment of drug dependence (n = 66), who were then approached via a telephone-administered change-orientated reflective listening intervention, based on principles of motivational interviewing, with informational adjunct. Outcome measures for the study sample (n = 29) were overall therapeutic commitment and motivation to follow up and actual clinical activity and willingness to deliver specified general health care interventions for drug misusers. RESULTS: Across the study sample, therapeutic commitment improved over time, whilst motivation did not. Change among individual practitioners in receipt of the intervention was observed in both positive and negative directions, and in four of the positive changers, this was judged attributable to the intervention. Positive changes were more than twice as frequent as negative changes. CONCLUSIONS: The direction and extent of change detected were encouraging. Further initiatives are needed to influence practitioner motivation, based on improved understanding of GPs' views on the delivery of primary care for drug misusers. (+info)
Homosexual and bisexual men's perceptions of discrimination in health services.
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Questionnaires were distributed to homosexual and bisexual male participants in the Multicenter AIDS Cohort Study and to homosexual and bisexual male patients with acquired immunodeficiency syndrome (AIDS) to determine whether the men believed they had been refused medical or dental treatment because of their sexual orientation or a condition related to the human immunodeficiency virus (HIV). Men with AIDS were significantly more likely (18%) to report being refused treatment by a doctor or dentist on the basis of a known or suspected HIV-related condition than were men who were seropositive (5%) or seronegative (1%). Significantly more respondents reported refusal of dental care than of medical care. (+info)
Medical futility and physician discretion.
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Some patients have no chance of surviving if not treated, but very little chance if treated. A number of medical ethicists and physicians have argued that treatment in such cases is medically futile and a matter of physician discretion. This paper critically examines that position. According to Howard Brody and others, a judgment of medical futility is a purely technical matter, which physicians are uniquely qualified to make. Although Brody later retracted these claims, he held to the view that physicians need not consult the patient or his family to determine their values before deciding not to treat. This is because professional integrity dictates that treatment should not be undertaken. The argument for this claim is that medicine is a profession and a social practice, and thus capable of breaches of professional integrity. Underlying professional integrity are two moral principles, one concerning harm, the other fraud. According to Brody both point to the fact that when the odds of survival are very low treatment is a violation of professional integrity. The details of this skeletal argument are exposed and explained, and the full argument is criticised. On a number of counts, it is found wanting. If anything, professional integrity points to the opposite conclusion. (+info)