Voice: structure, politics, and values in the medical narrative.
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OBJECTIVE: To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN: Point prevalence questionnaire survey of inpatients' medical and nursing records. SETTING: 10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS: Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES: Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS: Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS: In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients' suitability for resuscitation between doctors, nurses, patients, and patients' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.
OBJECTIVE: To describe barriers and facilitators to effective generalist-subspecialist communication in the care of children with chronic conditions. METHODS: We conducted 5 focus groups with 14 general pediatricians and 10 pediatric specialty providers to discuss factors that facilitate or obstruct effective communication. The specialty groups included 2 nurse practitioners; the rest were pediatricians from an academic medical center and the surrounding community. We performed a content analysis to generate groups of themes and classify them as barriers or facilitators, and we returned to the participants to solicit their feedback. RESULTS: We identified 201 themes in 6 domains: the method, content, and timing of communication; system factors; provider education; and interpersonal issues. Barriers to communication mostly involved the method of communication and system factors. Most facilitating themes promoted timely communication, understanding of the reasons for referral and the nature of the child's condition, or appropriate definition of generalist and specialist roles. Participants described numerous examples where communication had direct effects on patient outcomes. Generalists and specialists agreed on many issues, although specialists discussed the pros and cons of curbside consults at length whereas generalists emphasized the importance of their own education in the referral-consultation process. CONCLUSIONS: Efforts to improve communication between pediatric generalists and specialists in the care of children with chronic conditions should emphasize the importance of timely information transfer. The content of messages is important, but lack of receipt when needed is more of a problem. Improving generalist-subspecialist communication has great potential to improve the quality of care.
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This month's gatefold examines how physicians view and use information technology, the reasons for physician resistance to IT and strategies that hospital leaders use to overcome that resistance and incorporate IT into their organizations.
Hormesis has been defined as a dose-response relationship in which there is a stimulatory response at low doses, but an inhibiting response at high doses, resulting in a U- or inverted U-shaped dose response. Toxic agents that are detrimental to human health above certain threshold levels may induce positive effects at a dose that is significantly lower than the NOAEL level. In spite of the evidence for hormesis effects, the topic is still a matter of high controversy among toxicologists. Facing this ambiguity, the article raises the question: how should risk communication be arranged in a situation of high ambiguity, lack of empirical certainty about the effects, major policy dilemmas and significant equity problems? The article summarizes the main results of risk communication research and applies these results to the question of hormesis. First, it explains the main context variables that impact on the success or failure of any risk communication program. These refer to i) the levels of the risk debate, ii) the socio-political style of regulation, iii) different types of audiences, and iv) subcultural prototypes. Secondly, the paper addresses the major functions of risk communication: i) dealing with public perception; ii) gaining trust and credibility; iii) involving stakeholders in the communication process. The last section draws some conclusions for improving risk communication on issues of hormesis.
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Bivariate and multivariate analyses of the influence of demographic and sociocultural factors on contraceptive knowledge, attitudes and practice among currently married respondents in Uganda show that: (1) contraceptive knowledge is widespread, even among women with no education; (ii) the majority of the respondents have favourable attitudes towards contraceptive use; (iii) the level of contraceptive use is low in comparison with knowledge and attitudes. Post-primary education, ethnicity, residence, the presence of the spouse in the household and discussion of family planning with spouse were strong predictors of knowledge and favourable attitudes towards contraception. Secondary or higher education, discussion of family planning with spouse and urban residence strongly influenced contraceptive use, but child mortality did not. The use of condoms as a behavioural change to avoid contracting HIV/AIDS was low. The results suggest that, particularly in rural areas, family planning services are not meeting the needs of potential clients.
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This article reviews the historical and current controversies about the nature of clinical ethics consultation, as a way to focus on the place and responsibility of ethics consultants within the context of clinical conversation--interpreted as a form of dialogue. These matters are approached through a particularly compelling instance of the controversy that involves several major figures in the field. The analysis serves to highlight very significant questions of the nature and constraints of clinical situations, and the moral responsibility and legal accountability that are especially important for clinical ethics consultants.
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This paper examines problems of assessment and decision-making that result from poor or inadequate communication of indicators among the disciplines of public health, the physical sciences, and economics. The specific examples used are drawn from climate impacts in the Americas although the issues are more general to environmental health. In terms of physical processes, problems arise in confusion about indicators at different steps along the DPSEEA framework of environmental health indicators and general scientific uncertainty about the underlying physical processes. Communication between public health and economics is hindered by a lack of understanding of economic costs used in making decisions and the presence of implicit value judgments in economic analysis. Organizational structures may further inhibit the effective use of indicators. Finally, the paper discusses the Pan American Health Organization proposal to enhance the communication of indicators by using information technology networking to support communication among program managers and decision-makers at the national and local levels. The aim of this initiative is to establish a better environment for making decisions. The problem of cholera in Peru is shown as an example of the need for better communication.
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