[Directives for counseling services for the rehabilitation of handicapped. 17. Counseling of asthma patients].
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Asthma↗
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Results for “Directive Counseling”
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[Direction for counseling services for the rehabilitation of handicapped. 13. Counseling of upper limb amputees].
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Amputees↗
The fetus as a patient: an essential ethical concept for maternal-fetal medicine.
The objective of this paper is to provide an ethical analysis of the concept of the fetus as a patient and to identify the clinical implications of this concept for maternal-fetal medicine. The principles of beneficence and respect for autonomy are applied to the viable and previable fetus. We argue that the viable fetus is a fetal patient. The previable fetus is a fetal patient only when the pregnant woman confers such status on it. When the fetus is a patient, directive counseling for fetal benefit is ethically justified. When the fetus is not a patient, counseling should be non-directive.
Beneficence↗
Involuntary smoking and asthma.
Involuntary smoking is the third leading preventable cause of death, and among children it causes lower respiratory infections, middle ear disease, sudden infant death syndrome, and asthma. Half the world's children may be exposed to environmental tobacco smoke (ETS), exacerbating symptoms in 20% of children with asthma. Recent studies have reinforced previous conclusions that ETS exposure causes onset of childhood asthma and exacerbation of symptoms throughout life. The exact mechanisms by which this is accomplished are still unclear, as are the relative contributions of prenatal versus postnatal exposure. However, favorable health outcomes can be attained with reduced exposure. Among the few studies of ETS exposure reduction interventions, low-intensity advice methods appeared ineffective, and counseling parent smokers appeared successful. Direct counseling of school-aged children to avoid ETS has yet to be tested. Community norms may need to shift further in favor of protecting children and others from ETS before minimal interventions can be successful. This will require combined and ongoing efforts of the medical and public health establishments, in concert with legislation mandating tobacco-free public places and with ETS-related media campaigns.
Adolescent↗
[Psychological aspects of diagnostic methods in pregnancy].
Psychological effects and sequelae of prenatal diagnostics are presented using material of clinical trials and the results of client-centered counselling. All methods (ultrasound, alpha-fetoproteinscreening, amniocentesis and chorionic villous sampling) can only be understood with their effects upon mother - fetal bonding. A decision process, invasivity and discussion about a fetal malformation are the main characteristics of amniocentesis. High-risk populations like women with complicated pregnancies or advanced age profit most by prenatal diagnosis. The reactions and emotions of male partners are also discussed. The following guidelines for counselling are proposed: non-directive counselling dealing with facts and emotions, patient autonomy and preparation routines apt to reduce anxiety.
Adaptation, Psychological↗
The fetus as patient: implications for directive versus nondirective counseling for fetal benefit.
The authors provide an ethical account of the fetus as patient and identify the implications of that account for directive versus nondirective counseling for fetal benefit. They argue that such an account cannot be grounded in the independent moral status of the fetus. Instead, the concept of the fetus as patient is best understood in terms of the principle of beneficence. On the basis of this principle, the fetus is a patient depending on whether links can be established between the fetus and the child it can become. The viable fetus is a patient. Directive counseling for fetal benefit of the viable fetus is appropriate, provided that it takes account of the presence and severity of fetal anomalies, extreme prematurity, and obligations to the pregnant woman. The previable fetus, including the in vitro embryo and the near-viable fetus, is a patient solely as a function of the pregnant woman's autonomous decision to confer such status. If she confers such status, the fetus is a patient and directive counseling is appropriate, provided that it takes account of the factors noted above. If she denies such status, the fetus is not a patient and nondirective counseling is appropriate.
Beneficence↗
Patient attitudes to prenatal screening and termination of pregnancy at Groote Schuur Hospital: a two year prospective study.
A prospective 2-year study involving a questionnaire administered by a Genetic Counsellor was carried out to ascertain patient attitudes to prenatal screening and termination of pregnancy (TOP) at Groote Schuur Hospital. Women were questioned regarding their religious affiliation, education, ethnic group, reason for referral and age. Following ultrasonography, non-directive counselling was given regarding amniocentesis and TOP. Four hundred and sixty six women were investigated of whom 74% were of mixed ancestry, 14% Black and 12% White. Three hundred and sixteen persons were offered amniocentesis (67.8%). Muslim women accepted less frequently (66%) than other religious affiliations (79.7%) (p = 0.025). Overall amniocentesis acceptance was 75.9%. TOP was performed in 45 pregnancies (9.7%). Muslim women accepted TOP 1.33 times (C.I. 0.32-5.6) more frequently than those of other religious persuasions. Overall TOP acceptance rate was 76.3%. The mixed ethnic population of pregnant women seen at Groote Schuur Hospital readily accept prenatal screening and TOP following non-directive genetic counselling. The introduction of prenatal screening programmes for the prevention of severe congenital defects in this population would be successful and cost-effective.
Abortion, Therapeutic↗
Attitudes of Mexican geneticists towards prenatal diagnosis and selective abortion.
Prenatal diagnosis (PD) provides the physician information on whether the unborn fetus has a genetic or chromosomal disorder, and offers patients a new option: selective abortion. In the present study, we analyzed the answers Mexican geneticists provided to a few selected questions from a multinational survey designed by Wertz and Fletcher [1988: Am J Hum Genet 42:592-600]. The selected questions were related to the use of PD, the acceptance of selective abortion, and the self-reported directiveness of counselling following the diagnosis of a fetal anomaly. Our results show that the great majority of Mexican geneticists participating in the study agree with PD when medically indicated, but not on free demand. Specific cases stimulated the group on thinking more than the general statements provided in the survey. Although the majority agreed that PD should be available to all women, when faced with cases of nonmorbid maternal anxiety, paternity testing, and sex selection, the proportion of geneticists willing to perform the test decreased substantially. When counselling patients on a fetal anomaly, the minority would be as unbiased as possible, and this seems to be the tendency in developing countries where counselling, as stated in the respondents' comments, reflects the belief that the goal of genetics is the prevention of or opposition to abortion. Counselling was influenced by the severity of the disorder. The geneticists' personal attitude toward abortion in the same situations was stronger than when counselling others. Analysis of directiveness in counselling for fetal anomaly showed that older geneticists, with more years of experience in medical genetics, were more likely to be neutral. When counselling directively, the group showed an overall direction toward continuing affected pregnancies. However, older geneticists and those with more than 10 years of practice were more likely than their younger counterparts to counsel towards terminating affected pregnancies. In personal situations of fetal disorder, the general tendency was to abort; however, geneticists seeing more than 5 patients per week, and those who believe that religion is important, were more likely to reject abortion. The sample is representative of Mexican geneticists, and the main limitation of this study is that the geneticists have very little experience in PD, and that their responses were mostly based on theory. However, their opinions may influence the demand and the availability of PD and abortion, as well as the possibility of legalization of abortion on the basis of a fetal defect.
Abortion, Induced↗
The role of the critical care nurse in counseling families about advance directives.
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Advance Directives↗
Feasibility of a healthcare proxy counseling program for patients with Alzheimer's disease.
BACKGROUND: Although significant progress has been made in the implementation of advance directive counseling programs for cognitively intact patients, there is a paucity of information on the outcome of these programs with patients with Alzheimer's disease. This study investigated the prevalence of completed healthcare proxies in a sample of Alzheimer's disease outpatients, and the feasibility of a systematic proxy counseling program for this population. METHODS: The setting was a geriatric psychiatry clinic. Ninety-four patients with Alzheimer's disease were surveyed for their previous completion of a healthcare proxy. All patients with capacity and without a proxy were approached to complete the advance directive with a lay counselor. RESULTS: Thirty-two percent (n = 30) of patients had completed a proxy prior to the initiation of a counseling program. Of patients without proxies (n = 64), 89% had capacity to complete one. Seventy-nine percent subsequently completed a proxy through the counseling program. Hispanics were least likely to have had a proxy prior to initiation of the program, yet were very willing to complete the document. CONCLUSIONS: The majority of patients with Alzheimer's disease in an outpatient setting did not have healthcare proxies, yet had the capacity and motivation to complete this advance directive. With physician input regarding the presence of decisional capacity, a lay counselor successfully implemented the counseling process. These results support the initiation of similar counseling programs for Alzheimer's outpatients.
Journal Article↗
Pharmacist provided education and counseling for managing pediatric asthma.
A program to promote and assess the provision of family directed counseling by pharmacists on the understanding of pediatric asthma is discussed. The program consisted of two questionnaires separated by an educational intervention program. The initial questionnaire was developed to evaluate participants' understanding of asthma and its management. The aim of the intervention program was to improve this understanding through counseling, demonstration, and sharing of families' experiences with asthma. The second questionnaire assessed post-intervention knowledge including short-term retention of information. Before the intervention, few participants (14%) indicated that they were counseled by a pharmacist about the safe and effective use of asthma medications. Seventy-nine percent indicated that more information would aid them in better understanding asthma and possibly better controlling their child's illness. After the intervention, participants were able to correctly answer questions about asthma and medications used to manage the disease 78% of the time. This program offers one method for pharmacists to become involved in patient care through the provision of education and counseling. It also provides an avenue to encourage patients and their families to gain a deeper understanding of asthma and its management.
Adolescent↗
Counselling following diagnosis of a fetal abnormality: comparison of different clinical specialists in Mexico.
Most geneticists agree that counselling should be nondirective, and studies report that genetic counselling by geneticists is performed largely in a neutral style. However, couples at risk of having a child with a genetic condition may seek the advice of other physicians. The purpose of the present study was to describe the answers of four groups of specialists from Mexico City (internists, pediatricians, obstetricians, and neurologists) regarding how they would counsel a couple when prenatal diagnosis has shown that a fetus is affected by one of 17 different genetic disorders and to analyze the role of several variables in the development of their opinion. Our results show that physicians in these specialties are more likely to counsel directively than neutrally. Other variables did not influence the directiveness. With respect to direction of influence, internists, pediatricians, and neurologists are more likely to counsel terminating affected pregnancies than are obstetricians (P = 0.0002). Similarly, clinicians older than 37 years of age and those reporting that religion is not important to them counsel terminating affected pregnancies (P = 0.005 and P = 0.003, respectively). Physicians' gender and clinical experience with genetic diseases did not show statistically significant differences. Strong consensus among specialists was reached only on terminating pregnancies in anencephaly. A lowered and moderate consensus (51-75% agreement) was reached on continuing pregnancies with cleft lip and plate. A moderate measure of consensus for nondirective counselling was found among obstetricians regarding 14 of the 17 diseases in the study, whereas neurologists expressed a moderate measure of consensus on counselling the termination of pregnancies when the fetus was affected by neurological disorders. Hence, the approach to counselling was related in part to the fetal condition and in part to the clinician's specialty and age and the self-reported importance of religion. The data presented herein may not be representative of all Mexican physicians within the selected specialties; however, it is important to gather their opinions because they are involved in the care and treatment of genetic diseases and may have an important influence on the demand and availability of prenatal diagnosis and abortion.
Abortion, Induced↗
The rise of counselling and the return of alienism.
Current services for those with mental disorders show two trends. Psychiatric services are becoming concentrated on the care of those with "severe mental illness," largely (but unjustifiably) synonymous with chronic psychosis. The retreat of psychiatry from the care of those with non-psychotic mental disorders has helped the growth of counselling services for these patients. However, there is no evidence that non-directive counselling is effective for such disorders, in contrast to the evidence for the effectiveness of other treatments that are usually delivered by psychologists or community psychiatric nurses. By retreating from the concerns of general practice and general medicine, psychiatry is returning to the days of alienism: in Victorian terms, the care of "the mad." Possible consequences include increasing expectations of psychiatric services that cannot be met, a loss of skills within psychiatry, and increased demoralisation in the mental health services.
Counseling↗
The economics of employing a counsellor in general practice: analysis of data from a randomised controlled trial.
BACKGROUND: Counselling is currently adopted in many general practices, despite limited evidence of clinical and cost effectiveness. AIM: To compare direct and indirect costs of counsellors and general practitioners (GPs) in providing care to people with emotional problems. METHOD: We carried out a prospective, randomized controlled trial of non-directive counselling and routine general practice care in 14 general practices in north London. Counsellors adhered to a Rogerian model of counselling. The counselling sessions ranged from one to 12 sessions over 12 weeks. As reported elsewhere, there were no differences in clinical outcomes between the two groups. Therefore, we conducted a cost minimisation analysis. We present only the economic outcomes in this paper. Main outcome measures were cost data (service utilisation, travel, and work absence) at baseline, three months, and nine months. RESULTS: One hundred and thirty-six patients with emotional problems, mainly depression, took part. Seventy patients were randomised to the counsellors and 66 to the GPs. The average direct and indirect costs for the counsellor was 162.09 Pounds more per patient after three months compared with costs for the GP group; however, over the following six months the counsellor group was 87.00 Pounds less per patient than the GP group. Over the total nine-month period, the counsellor group remained more expensive per patient. CONCLUSIONS: Referral to counselling is no more clinically effective or expensive than GP care over a nine-month period in terms of direct plus indirect costs. However, further research is needed to establish indirect costs of introducing a counsellor into general practice.
Costs and Cost Analysis↗
The effect among older persons of a general preventive visit on three health behaviors: smoking, excessive alcohol drinking, and sedentary lifestyle. The Medicare Preventive Services Research Team.
BACKGROUND: The U.S. Congress mandated evaluations, initiated in 1989, to determine whether extending Medicare benefits to include preventive services would improve health status, reduce costs of care, and improve health risk behaviors of beneficiaries. METHODS: The Johns Hopkins Medicare Preventive Services Demonstration was a randomized trial in which Medicare beneficiaries were assigned either to an intervention group that was offered yearly preventive visits for 2 years and optional counseling visits to their primary care provider or to a control group that received usual care. This report describes the effect of the intervention over a period of 2 years on smoking, problem alcohol use, and sedentary lifestyle. RESULTS: Differences were observed between the intervention and control groups in the extent to which changes occurred in smoking and problem alcohol use, but none of the differences was statistically significant. The proportion of smokers who quit was higher in the intervention group than in the control group (24.2 vs 17.9%, P = 0.09). However, a higher proportion of problem drinkers in the control group improved (67.1 vs 57.0%, P = 0.183). There was virtually no difference between the intervention and the control groups in the proportion with improvement in sedentary lifestyle. CONCLUSIONS: This study demonstrates the difficulty of bringing about health behavior change in older patients in the course of a yearly preventive visit for 2 years with their primary care physician when the visit encompasses screening and immunizations, as well as health behavior counseling directed by the physician. Further study is required to determine whether a more intense program of counseling for health behavior change among older persons by their primary care providers would be effective.
Aged↗
A reproducible modified method for direct preparation of chorionic villi cytogenetic analysis.
Chorionic villi are finger like projections, which surrounds the embryonic sac in early pregnancy and will later form the placenta. The outer layer of the chorionic villi consists of trophoblast cells. These cells are actively dividing and can be used for direct preparation or short-term culture for prenatal diagnosis of chromosomal abnormalities. We herein describe a 100% reproducible modified technique for one day direct culturing (direct preparation) of trophoblast cells. Direct preparation of chorionic villi provides the physician with additional diagnostic information during prenatal diagnosis and genetic counseling. Direct preparation also eliminates the risk of maternal cell contamination. This method was 100% reproducible provided all the precautions mentioned herewith were taken into consideration and can be completed in 45 minutes upon arrival of the samples in the laboratories.
Cell Culture Techniques↗
Clinical implications of respect for autonomy in the psychiatric treatment of pregnant patients with depression.
Major depression, as well as depressive symptoms that do not meet the full diagnostic criteria for a diagnosis of depression, can chronically and variably affect a woman patient's decisions about the management of pregnancy, including the decision about whether to continue a pregnancy. Depression also has potential adverse consequences for the pregnant woman and her pregnancy. However, little attention has been given to the ethical challenges posed by the psychiatric management of depression during pregnancy. The psychiatrist should balance respect for the autonomy of the depressed woman with beneficence-based obligations to the pregnant woman, and also to the fetus, when the fetus is viable. The authors recommend strategies for assessing the decision-making abilities of pregnant patients with depression and for enhancing their autonomy. They suggest that nondirective counseling should generally be used with pregnant patients with depression when the fetus is previable and that directive counseling is ethically justifiable when the fetus is viable.
Abortion, Induced↗
A segmentational analysis of prescription drug information seeking.
Drug information-seeking proclivities were examined using data from a telephone survey of 835 individuals who had obtained new outpatient prescriptions within the previous 4 weeks. Factor analytic and clustering techniques were used to segment patients based on the source and nature of drug information received in conjunction with the prescription. A four-cluster solution appeared to represent the most stable, distinct, yet homogeneous solution for the data. The groups were named "physician reliant" (40%), "pharmacist reliant" (19%), "questioners" (7%), and "uniformed" (34%). The four groups were compared for demographic, situational, and attitudinal differences. The physician-reliant group appeared most satisfied with the direct counseling of the doctor. Although this group may have sought additional information, the information appeared to reinforce the physician's directions. The pharmacist-reliant group often obtained prescriptions at independent pharmacies and tended not to rely on magazines or reference books for additional information. The questioners were often taking multiple medications. This group tended to seek out reference information from nonprofessional sources and reported several barriers to seeking information from professionals. The uninformed group was the oldest, tended to receive little information, and was more likely than the other groups to agree that one need not ask questions if one trusts the doctor. Different types of patient education programs were recommended as appropriate for each of the four groups. Motivational messages directed to the uninformed segment appeared to be the largest unmet need in patient-oriented prescription drug education.
Adult↗