Why is recruitment to trials difficult? An investigation into recruitment difficulties in an RCT of supported employment in patients with severe mental illness.
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The Competency-Based Training in Intensive Care Medicine in Europe (CoBaTrICE) Italian collaborative: national results from the Picker survey.
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BACKGROUND: The aim of the Competency-Based Training in Intensive Care Medicine in Europe (CoBaTrICE) project is to create an internationally acceptable competency-based training program for specialists in intensive care medicine. The CoBaTrICE Project has performed a survey, in collaboration with the Picker institute, United Kingdom, to identify desirable characteristics of Intensive Care Unit (ICU) specialists, as expressed by patients and their relatives. METHODS: A questionnaire was developed to assess 21 elements of professional competence. Each element was assigned to one of four categories of a Likert scale: 1=essential; 2=very important; 3=not too important; 4=does not matter. The results were dichotomized into essential (score: 1) and not essential (scores: 2-4) categories. Further, the documents were related to three key concepts: "medical skills and competencies", "communication with patients", and "communication with relatives". Questionnaire statements grouped by theme were also ranked for each item using a number: 1=highest rank; 21=lowest rank. Free text responses were also invited. RESULTS: Ten Italian ICUS were enrolled in the study. There were 249 questionnaires completed (18% total return rate). CONCLUSION: Priority in Italy was given to medical skills and competence. Involvement of patients and relatives in decision-making processes were among the items considered least important. Italian families preferred a paternalist approach to the end of life decision-making process. (+info)
Dependence and caring in clinical communication: the relevance of attachment and other theories.
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Autonomy, religious values, and refusal of lifesaving medical treatment.
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The principal question of this paper is: Why are religious values special in refusal of lifesaving medical treatment? This question is approached through a critical examination of a common kind of refusal of treatment case, one involving a rational adult. The central value cited in defence of honouring such a patient's refusal is autonomy. Once autonomy is isolated from other justificatory factors, however, possible cases can be imagined which cast doubt on the great valuational weight assigned it by strong anti-paternalists. This weight is sufficient, in their estimation, to justify honouring the patient's refusal. There is thus a tension between the strong anti-paternalist's commitment to the sufficiency of autonomy and our intuitions respecting such cases. Attempts can be made to relieve this tension, such as arguing that patients aren't really rational in the circumstances envisaged, or that other values, such as privacy or bodily integrity, if added to autonomy, are sufficient to justify an anti-paternalistic stance. All such attempts fail, however. But what does not fail is the addition of religious freedom, freedom respecting a patient's religious beliefs and values. Why religious freedom reduces the tension is then explained, and the specialness of religious beliefs and values examined. (+info)
Involving patients in do not resuscitate (DNR) decisions: an old issue raising its ugly head.
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A recent paper in this journal (1) suggests that involving terminally ill patients in choices concerned with Cardio-Pulmonary Resuscitation (CPR) produces 'psychological pain' and therefore is ill-advised. Such a claim rests on anecdotal observations made by the authors. In this paper I suggest that drawing conclusions in ethics, no less than in science, requires a rigorous framework and cannot be relegated to personal observation of a few cases. The paper concludes by suggesting that patients, if we acknowledge their valid interest in making their own choices, must themselves be allowed to make a prior choice about choosing. Those who may not wish to choose may properly be relieved of this burden and may allow another to choose for them. Routinely allowing others to make choices for competent adults, however, is likely to decrease communication with the dying patient and to introduce an atmosphere of suspicion and fear and to exclude the competent patient from his/her rightful place in the community. (+info)