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PubMed1992

Informed consent and the prescription of nonsteroidal antiinflammatory drugs.

OBJECTIVE: To examine disclosure of side effects of nonsteroidal antiinflammatory drugs (NSAIDs) and to identify patient- and physician-specific factors associated with greater disclosure. METHODS: Forty-six encounters between rheumatologists and new adult outpatients who were prescribed an NSAID they had not been taking prior to the visit were audiotaped. Reviewers coded the NSAID prescribed, specific side effects mentioned, demographic features of patients and physicians, and patient clinical characteristics. Neither patients nor physicians were aware that side effect disclosure was being studied. RESULTS: A mean of 1.7 side effects was mentioned per encounter. Epigastric discomfort was mentioned in 72% of encounters, while other side effects, including hepatic, renal, hematologic, or central nervous system effects, were mentioned in < or = 15% of encounters. Three factors were identified as independent predictors of less disclosure of side effects: senior clinician (versus less experienced), patient not taking another NSAID immediately prior to the visit, and patient age < 40. Increased disclosure by less experienced clinicians occurred exclusively with patients who were taking another NSAID prior to the visit. CONCLUSION: Disclosure of side effects other than epigastric discomfort to patients who are prescribed a new NSAID is limited. Patients not taking NSAIDs previously, who presumably have the most to gain from such discussions, are told the least. These results have implications with regard to doctor-patient decision-making and malpractice litigation in the outpatient setting.

Adult↗
PubMed1995

Attitudes, knowledge, and practices of otolaryngologists treating patients infected with HIV.

The AIDS epidemic has become one of the most important public health problems of this century. As the prevalence of HIV infection continues to rise, health care practitioners in all geographic regions can expect greater clinical exposure to patients infected with HIV. We conducted an anonymous survey of all practicing otolaryngologists in Ohio and California to investigate regional differences in attitudes, knowledge, and practices regarding the care of patients infected with HIV. We also examined the data with respect to year of completion of residency training to identify differences in attitudes or practices among otolaryngologists who trained in the era of AIDS (post-1982 graduates) in comparison with their predecessors (pre-1982 graduates). In comparison with Ohio otolaryngologists, California otolaryngologists reported more frequent clinical encounters with HIV-infected patients and displayed significantly better knowledge regarding the otolaryngologic aspects of HIV infection. Californians were more likely to support the right of an HIV-infected physician to maintain an unrestricted practice and would be less likely to disclose their HIV status to their patients and hospital if they were to become infected with HIV. Post-1982 graduates had more frequent encounters with HIV-infected patients than did pre-1982 graduates and demonstrated a better fund of knowledge. Although Californians were more likely than Ohioans to routinely double glove in surgery, the overall double gloving rate was low at 21%. Californians were no more likely than Ohioans to routinely use protective eyewear, water-impervious gowns, or indirect instrument-passing techniques in surgery. No differences were observed in prevalence of protective surgical precautions between pre-1982 and post-1982 graduates.(ABSTRACT TRUNCATED AT 250 WORDS)

California↗
PubMed1990

Patient advocacy and whistle-blowing in nursing: help for the helpers.

This article examines the phenomenon of whistle-blowing and its antecedent dynamics, including invidious organizational tactics that are employed to silence patient advocates. Moral distress and moral outrage are identified and described as manifestations of the stress that nurses experience when acts of patient advocacy are subverted. Recommendations are offered to empower and protect present and future practitioners who may be faced with having to take on the role of whistle-blower. Research initiatives are also suggested.

Decision Making↗
PubMedDate not supplied

Informed consent: law, clinical reality, and the role of the family physician.

Informed consent is typically seen as most relevant to surgical and other invasive specialties. Although family physicians perform fewer high-risk procedures, they are nonetheless extensively involved in the informed consent process because of the comprehensive and continuing nature of the family physician-patient relationship. Family physicians have a particularly important role in helping their patients to understand what diagnostic or therapeutic alternatives are available. Family physicians have an independent role in the informed consent process, as well as a collaborative role in the context of consultation and referral. Legal rules that require disclosure of alternatives to the patient by the treating physician are examined in the context of the family physician's role as a coordinator of patient care. Practical suggestions regarding discussion of alternatives, extent of disclosure, coordination with consulting physicians, and encouragement of patients' participation in discussions are offered.

Disclosure↗
PubMed2005

Depressive symptomatology, youth Internet use, and online interactions: A national survey.

PURPOSE: To investigate the online communications and self-disclosure practices of youth reporting depressive symptomatology. METHOD: The Youth Internet Safety Survey was a nationally representative telephone survey of 1501 Internet-using youth between the ages of 10 and 17 years, and one caregiver in their household. Fifty-three percent of youth participants were male and 73% were white race. The purpose of the survey was to obtain prevalence rates for unwanted sexual solicitation, harassment, and unwanted exposure to sexual material among young people online. Questions about current depressive symptomatology were also queried; this variable was defined based upon the DSM-IV definition of a major depressive episode: major depressive-like symptomatology (5+ symptoms of depression and functional impairment in at least one area); minor depressive-like symptomatology (3+ symptoms of depression); mild or no depressive symptomatology (<3 symptoms of depression). Data were cross-sectional and collected between the fall of 1999 and spring 2000. Multinomial logistic regression was used to estimate the conditional odds of reporting DSM-IV-like major or minor depressive symptomatology vs. mild/no symptomatology given the indication of self-disclosure practices and interactions with others online. Males and females were assessed separately. RESULTS: Talking with strangers online, using the Internet most frequently for e-mailing others, and intensity of Internet use differentiated youth reporting depressive symptoms from asymptomatic peers. Report of depressive symptomatology was not related to most measures of general Internet use nor gender differences. Personal disclosure was significantly more likely to be reported by both young men and young women who reported major depressive symptomatology vs. mild or no symptomatology. Differences were observed for how adolescents choose to self-disclose; females posted pictures of themselves, whereas males were more likely to provide personally identifiable information. Finally, most gender-related variation reflected differences in the magnitude of Internet associations with depressive symptoms rather than the types of Internet use, access, or online communications. CONCLUSIONS: Youth-reported depressive symptomatology is associated with differences in online interactions and self-disclosure practices.

Adolescent↗
PubMed1997

Disclosure practices and cultural narratives: understanding concealment and silence around cancer in Tuscany, Italy.

Disclosure practices are embedded in and enact personal, professional, and societal narratives. These narratives are not given but contested and evolving. The medical arena constitutes an important social space in which this contestation, reproduction and change take place. More specifically, based on ethnographic and cultural survey data, we describe and interpret the cultural sense of "not telling" about cancer within the local world of Tuscany, Italy. We locate the traditional practice of non-disclosure of cancer diagnoses within a larger cultural narrative we call "social-embeddeness", a narrative of social unity and hierarchy, of protection from or adaptation to the inevitable necessities of life, in part by using narrative itself to construct a sense of group protection. This narrative is being challenged, as it confronts other medical and societal narratives, such as one originating from the United States and embedded in health care practices like open disclosure, informed consent, Advanced Directives, and the Patient Self-Determination Act, what we call the "autonomy-control narrative". Explicit disclosure to a patient about his or her illness and the future plays an important role in actualizing this narrative, in helping in the quest to control one's destiny, eliminate uncertainty and necessity, and foster a person's identity as singular and sovereign over him/herself. The concept "narrative" highlights the ideology and intent of people's practices, not just "outcome", and helps us understand contradictions in various disclosure contexts as partly due to multiple cultural narratives in play. Considering some of the practices and understandings embedded within and reproduced by the larger cultural narratives also allows us to track the dynamics of history and individual biography, to locate and compare approaches to disclosure across time and space, and to avoid the pitfalls of cultural determinism and cultural stereotypes.

Bioethics↗
PubMed2003

Does full disclosure of medical errors affect malpractice liability? The jury is still out.

BACKGROUND: Mandatory disclosure of medical errors has been advocated to improve patient safety. Many resist mandatory disclosure policies because of concerns about increasing malpractice exposure. It has been countered that malpractice liability actually decreases when there is full disclosure of medical errors. A comprehensive literature search was conducted to determine what is known about the impact of full disclosure on malpractice liability. METHODS: Electronic searches of multiple databases were supplemented with hand searches of bibliographies and communication with recognized experts in the field. RESULTS: Screening the titles, abstracts, and, in many cases, the full articles from more than an estimated 5,200 citations resulted in identification of one published study directly examining malpractice liability when a policy of full disclosure was implemented. DISCUSSION: Despite extensive literature on the impact of disclosure on malpractice liability, few well-designed studies have focused on the real-world impact on the volume and cost of suits following implementation of a full disclosure policy. Many articles examine why patients sue their doctors, suggesting that some lawsuits may be averted by disclosure, but the articles do not allow us to estimate the additional suits that would be created by disclosure. Additional studies addressing the effect of disclosure on malpractice liability are needed.

Compensation and Redress↗
PubMed2005

Self-disclosure in romantic relationships and friendships among American and Japanese college students.

The author examined whether the level of self-disclosure would differ across four types of relationships--passionate love relationships, companionate love relationships, same-sex friendships, and cross-sex friendships--and across cultures: American culture and Japanese culture. Participants were 145 college students (64 Americans and 81 Japanese). The results supported three hypotheses: (a) Japanese students scored lower in self-disclosure than American students, regardless of relationship types, (b) self-disclosure was higher in same-sex friendships than in cross-sex friendships both among American participants and among Japanese participants, and (c) self-disclosure was higher in romantic relationships than in friendships both among American students and among Japanese students. However, the correlation between self-disclosure and passionate love was not stronger than the correlation between self-disclosure and companionate love. The author discussed the present study's findings and contribution.

Adolescent↗
PubMed2006

Between a rock and a hard place: disclosing medical errors.

BACKGROUND: Healthcare-related errors cause patient morbidity and mortality. Despite fear of reprimand, laboratory personnel have a professional obligation to rapidly report major medical errors when they are identified. Well-defined protocols regarding how and when to disclose a suspected error by a colleague do not exist. PATIENT: We describe a woman with a well documented allergy to sulfamethoxazole who was treated with sulfadiazine that led to toxic epidermal necrolysis. After the patient's death, the laboratory medicine resident was asked by one of the patient's physicians to measure serum sulfadiazine, but only if the results were not reported in the patient's electronic medical record. The case was brought to the attention of a laboratory medicine faculty member and the hospital risk management team. ISSUES: Laboratorians are patient fiduciaries and are responsible for reporting errors. Most medical associations have codes of ethics that address disclosure of incompetence and errors, although the AACC's Guide to Ethics does not. New types of error, risk management, and root-cause analyses help to shift the focus to system errors and away from individuals' errors. This can lead to a healthcare environment that encourages truth and disclosure rather than fear and reprimand. Disposition: The individuals involved in the presented case fulfilled their fiduciary duty to the patient by reporting this incident. An extensive investigation showed that, in fact, no medical errors or misconducts had occurred in the care of the patient.

AIDS-Related Opportunistic Infections↗
PubMed2000

Physicians' ethical beliefs about cost-control arrangements.

BACKGROUND: Although much has been written about the ethics of new methods of health care financing, little is known about the extent to which physicians experience these cost-control arrangements as ethical problems. METHOD: A cross-sectional telephone survey of 1,549 physicians, 8 to 17 years after residency, randomly selected from 75 US metropolitan service areas (response rate, 74.0%). RESULTS: Only 17.0% believed that financial incentives to limit services are ethically acceptable. Although 52.9% thought that physicians should try to abide by guidelines discouraging the use of interventions with possible but unproven benefit, only 14.5% thought such guidelines should be enforced by payers. Only 5.7% thought that it was morally acceptable for payers to discourage physicians from telling patients about their personal financial incentives, and only 9.1% found compliance with such restrictions morally acceptable. Changes in the health care system in the past 5 years were believed to have had a negative impact on their own patients' trust in them by 50.6%, and 80.8% believed that changes in the health care system in the past decade have diminished physicians' commitment to an ethic of undivided loyalty to patients. In multiple regression analysis, physicians who reported that the overall personal financial incentives in their practices encouraged them to reduce services were significantly more likely to have ethical objections to such incentives, to believe their own patients' trust in them had diminished, and to believe that the ethic of undivided loyalty to patients had diminished. CONCLUSIONS: Many of the methods now commonly used to influence medical decision making are considered ethically objectionable by most midcareer physicians. Whether their ethical disquiet about these arrangements is justified cannot be answered from these data.

Attitude of Health Personnel↗
PubMed1996

Ethical dilemmas faced by critical care nurses in clinical practice: walking the line.

The experience of the critical care nurse includes frequent ethical dilemmas, both in patient care and in professional relationships. The moral development of the critical care nurse is presented in terms of learning theory, perceptive transformation, and ethical theory as it applies to the predominantly female profession of nursing. Four case studies and verbatim accounts of the experiences of critical care nurses illustrate moral development.

Adult↗