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PubMed2003

When we give more: reflections on intangible gifts from therapist to patient.

Since Freud's time, psychoanalytically oriented therapists have been wary of accepting gifts from patients, and have also been reluctant to give them to patients. This article first provides a literal definition of the word "gift," and then defines it within the context of the therapeutic relationship. It then reviews the literature on gifts and presents clinical examples describing five categories of offerings from therapist to patient, experienced by the patient as gifts, namely: 1. the gift of a transitional object; 2. the gift of self-disclosure; 3. the gift of time; 4. the gift of physical touch; and 5. the gift of developmental presence. Examples of therapists' considering but not offering gifts to patients are discussed and viewed from the perspective of whether they are requested by the patient, whether they arise from within the therapist, or whether they are offered in a context of reciprocation. Guidelines for how and when the therapist could attempt such interventions most safely are suggested, placing particular emphasis on counter-transferences.

Countertransference↗
PubMed1997

Lesbian coming out as a multidimensional process.

Coming out for lesbians is discussed as a multidimensional process. Four dimensions are presented and explored. First is sexual identity formation which encompasses development of lesbian sexuality and awareness of being a lesbian. Second is disclosure of sexual orientation to others. Third is sexual expression and behavior. Fourth is lesbian consciousness which refers to how lesbians see themselves in relation to the social environment, including lesbian and gay communities. These dimensions are examined in relation to existing theories and research about lesbian coming out processes. Further, there is a discussion of coming out and demographic differences among lesbians. The possible impact of age, race, ethnicity, religion, geographic location, income, employment, and education on lesbian coming out are considered.

Female↗
PubMed2001

Disclosure of adverse events and errors in healthcare: an ethical perspective.

Adverse events and medical errors affecting patient care are recognised internationally as major problems in medicine. The failure of health care professionals and health institutes to address this problem has threatened to undermine public confidence in the health care system as a whole. Less focus has been directed at the ethical issues raised by negative outcomes of care, specifically the issue of disclosure. Efforts to prevent negative outcomes of care must be supplemented by policies of increased honesty and openness with patients and their families about adverse incidents. Disclosure should be made easier, not riskier, for healthcare practitioners so clinicians can learn from mistakes and improve patient care. Ethical guidelines for error disclosure must distinguish between disciplinary action and reporting of adverse incidents. Disclosure of negative outcomes requires tact and good communication skills. Healthcare institutions should provide training for the clinicians in this area, if necessary. As a general rule, patients should be informed of unexpected adverse incidents as soon as possible. Medical staff should be rewarded for adverse event reporting and protected from institutional retaliation on account of errors made in health care.

Attitude of Health Personnel↗
PubMedDate not supplied

Attitudes of patients towards voluntary human immunodeficiency virus counselling and testing in two Nigerian tertiary hospitals.

BACKGROUND: Despite new scientific evidence establishing the benefits of counselling and testing as key elements in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) prevention strategy, inappropriate HIV screening without consent and counselling is frequent in Africa. Presumed high rejection rate of HIV test has been adduced to this practice. OBJECTIVE: To determine the acceptability of HIV conselling and testing among Nigerians. METHODS: Consecutive sixty indigenous Nigerians aged 35.10+/-11.31 years with male: female ratio of 2:1, and made of clients with clinically suspected AIDS (20), diseases unrelated to AIDS (15), dermatological problems (10), sexually transmitted diseases (9), and asymptomatic persons (6) were studied. RESULTS: Fifty-three (88.3%) subjects gave informed consent to HIV screening. Of the 53 consenters, 32 (60.4%) were seropositive while 21 (39.6%) were seronegative. Five clients (9.4%) (1seropositive + 4 seronegative consenters) did not turn up for their results, and 2 (3.8%) seronegative consenters did not want to know their serostatus. The reactions to disclosure of seropositive results included grief 9 (28.1 %), indifference 8 (25 %), surprise 5 (15.6%), family concern 5 (15.6%), denial 3 (9.4%) and suicidal ideation 2 (6.3%). Thirteen (40.6%) seropositive clients showed willingness to disclosure of their serostatus to family members including the father (58%), senior brother (23%), wife (11%) and others (8%). Direct cost of screening was N400.00 (U$3.10) per client. An average of 18 minutes per client was spent on counselling. CONCLUSIONS: This study demonstrates the feasibility of VCT in Nigerian hospitals.

AIDS Serodiagnosis↗
PubMed1999

Prevalence and effects of child sexual abuse in a poor, rural community in El Salvador: a retrospective study of women after 12 years of civil war.

OBJECTIVE: The purpose of this retrospective study was to examine the epidemiology of child sexual abuse (CSA) among women in a poor, rural community in El Salvador, which was recovering from a 12-year civil war. METHODS: A cross-sectional, door-to-door survey was administered to 83 women. The LA Times Sexual Abuse Survey was used to determine the prevalence of CSA. The Hopkins Symptom Checklist (HCL) was used to measure long-term psychological sequelae of abuse (somatization, anxiety, depression, interpersonal sensitivity, and obsessive-compulsive traits). Information also was obtained about participation and number of relatives killed in the country's 12-year civil war. RESULTS: Of the 83 women interviewed, 14 (17%) reported a total of 21 experiences of CSA. The median age of abuse was 14 years. The majority of perpetrators (90.4%) were strangers, friends, or neighbors. None was a parent. The only significant difference between abused and non-abused women was on the depression measure, where abused women showed more pathology. After controlling for the number of relatives killed in the war, however, that difference failed to reach statistical significance. CONCLUSIONS: Differences in the epidemiology of CSA from that of other countries may be secondary to a different social structure in the rural Salvadoran community and non-disclosure by the women surveyed. The lack of difference in psychological symptoms between abused and non-abused women may be related to the different characteristics of the abuse and perpetrators. It also may be secondary to adverse social conditions such as poverty and war, which could obscure the long-term effects of CSA.

Adolescent↗
PubMed1993

Issues in the provision of health care to Soviet emigrants.

Political and economic unrest in the former Soviet Union has been associated with an influx of refugees to the United States. The medical staff at our health maintenance organization perceived health care provision to the Soviet refugees as a goodwill opportunity, but soon realized that providing health care to this subpopulation of patients was very difficult. This was often related to cross-cultural differences regarding disclosure of medical information to the patient, acute care provision, and payment systems. Immigrants' expectations of US medicine are incredibly high. The interpreter plays a key role in facilitating communication between the health care team and the immigrant, yet the use of an interpreter has several inherent problems. Recognition of the problems and knowledge of the cross-cultural differences will likely improve rapport between health care personnel and immigrants.

Communication Barriers↗
PubMed1999

The politics of disclosing female sexual abuse: a case study of Palestinian society.

INTRODUCTION: This paper argues that, by understanding the socio-cultural and political context within which disclosure or non-disclosure of sexual abuse takes place we are better able to develop an analytical framework that might shape culturally sensitive social policy towards sexual abuse and thereby reduce it. METHOD: The data for the study were extracted from records available on 38 cases of sexually abused Palestinian girls, as well as interviews conducted with victims and their parents whenever possible. In-depth interviews were conducted with 19 professionals who dealt with these 38 cases. FINDINGS: Contextual analysis of the data revealed that acknowledgment of sexual abuse took place only in situations where the abuse was extremely traumatic, publically apparent, and the victim absolved of blame. Disclosure resulted in approximately 10% of the cases in the killing of the victim. Responses involving measures such as hymen reconstruction, marriage to the rapist, and abortion were used by family and society to "nullify" sexual abuse. The intricacies bearing on the decision to disclose or not disclose sexual abuse were discussed within a socio-cultural and political frame of reference. A paradigm of analysis is provided to clarify this complex relationship.

Abortion, Induced↗
PubMed1997

Disclosing HIV status and sexual orientation to employers.

Seropositive gay and bisexual men who reveal their sexual orientation or HIV/AIDS status to their employer risk discriminatory reprisals. However, non-disclosure may limit potential social, emotional, and tangible support. Among our sample of 389 seropositive gay and bisexual men employed in the US, 52% were 'out' to their employer and 35% had disclosed their serostatus to him or her. Among gay men, employer awareness of their sexual orientation was related to their being European American (vs Latino or African American), being HIV-seropositive for more than 4 years, and having a gay or bisexual employer. Disclosure of HIV infection in the total sample was related to being European American, HIV-seropositive for more than 4 years, symptomatic (vs asymptomatic), 'out' at work, and having a gay or bisexual employer. Men who had informed their employers of their HIV status reported consequences that were substantially more positive than those anticipated by men who had not disclosed. Policy and research implications for improving the work environment for gay and bisexual men living with HIV are considered.

Attitude to Health↗
PubMed1999

Risk management: extreme honesty may be the best policy.

This paper reviews a humanistic risk management policy that includes early injury review, steadfast maintenance of the relationship between the hospital and the patient, proactive full disclosure to patients who have been injured because of accidents or medical negligence, and fair compensation for injuries. The financial consequences of this type of policy are not yet known; however, one Veterans Affairs medical center, which has been using humanistic risk management since 1987, has had encouragingly moderate liability payments. The Department of Veterans Affairs now requires such a policy for all of its facilities; therefore, comprehensive experience may be only a few years away.

Compensation and Redress↗
PubMed1996

[Disclosure of X-ray results by the radiologist? Yes, say the patients. May be, say the physicians].

How radiologists should respond to patient's queries about x-ray results is discussed in this article outlining the views of Swedish patients, radiologists and clinicians. Most patient would like to be told the result at the x-ray department; but although radiologists are more inclined than clinicians to let the radiologist disclose the results, comparison of Swedish views on this issue with those outlined in an American report suggests both categories of Swedish physicians to be more reluctant than their American counterparts to allow the radiologist to disclose results.

Attitude of Health Personnel↗
PubMed1995

Incest revisited: delayed post-traumatic stress disorder in mothers following the sexual abuse of their children.

The case histories of four women who developed symptoms of post-traumatic stress disorder following the disclosure of the sexual abuse of their daughters are presented. These individuals also exhibited comorbid symptoms of depression and personality disorders. Awareness of the sexual abuse of their daughters catalyzed a reliving of their own childhood victimization. The psychodynamics operating in these cases, as well as treatment strategies are also presented. A brief follow-up of three of the four cases is included.

Adult↗
PubMed2002

Rights and duties of HIV infected health care professionals.

In 1991, the CDC recommended that health care workers (HCWs) infected with HIV or HBV (HbeAg positive) should be reviewed by an expert panel and should inform patients of their serologic status before engaging in exposure-prone procedures. The CDC, in light of the existing scientific uncertainty about the risk of transmission, issued cautious recommendations. However, considerable evidence has emerged since 1991 suggesting that we should reform national policy. The data demonstrates that risks of transmission of infection in the health care setting are exceedingly low. Current policy, moreover, does not improve patient safety. At the same time, implementation of current national policy at the local level poses significant human rights burdens on HCWs. Consequently, national policy should be changed to ensure patient safety while protecting the human rights of HCWs. This article proposes a new national policy, including: (1) a program to prevent bloodborne pathogen transmission; (2) a responsibility placed on infected HCWs to promote their own health and well-being and to assure patient safety; (3) a discontinuation of expert review panels and special restrictions for exposure-prone procedures; (4) a discontinuation of mandatory disclosure of a HCW's inflection status; and (5) the imposition of practice restrictions if a HCW is unable to practice safely because of a physical or mental impairment or failure to follow careful infection control techniques. A new national policy, focused on management of the workplace environment and injury prevention, would achieve high levels of patient safety without discrimination and invasion of privacy.

Blood-Borne Pathogens↗
PubMedDate not supplied

Public disclosure of process and outcome measures.

There is a long history of resistance to public disclosure of data comparing the quality of doctors or hospitals. Examples of data ultimately disclosed are risk-adjusted cardiac bypass surgery mortality data, cesarean section rates, doctor immunization practices, and state medical board rates of serious disciplinary actions. Recent studies on postoperative infection rates in Veterans' Affairs hospitals show large differences even after risk adjustment. It is inevitable that more comparative quality data involving both the process and outcome of medical care will be made public after proper adjustment for risks.

Benchmarking↗
PubMed1996

Pre-operative information in mastoidectomy: what about the facial nerve and hearing loss?

Facial nerve palsy and hearing impairment are accepted risks of mastoid surgery. However, at present there are no guidelines as to whether a patient must be informed of the potential risk to the facial nerve and hearing during mastoid surgery. Currently the law states that the surgeon should do what a 'reasonable doctor' would do under similar circumstances but exactly what this entails is not clear. A recent publication established that 16 per cent of British surgeons did not tell their patients about the risk to the facial nerve and 13 per cent about the risk of hearing loss. A survey of South African surgeons showed a different picture with only 57 per cent of surgeons informing their patients of possible facial nerve injury and 71 per cent about hearing loss. One of the reasons stated was that this information might deter the patient from having a necessary operation. This raises the question of excessive information disclosure and its possible legal consequences if excessive information leads a patient into making an unbalanced judgment owing to his/her lack of medical training, prejudices or personality. In this survey 25 per cent of South African surgeons have had patients refuse surgery after being informed of the risk to facial nerve and hearing. The decision whether to inform the patient about these risks should be individualized for every patient after the surgeon has audited his/her results and assessed the patients prejudices, personality and level of education.

Facial Nerve Injuries↗
PubMed2001

Disclosure of HIV status in the workplace: considerations and strategies.

Maintaining a role in the workplace despite significant health concerns can be important in meeting an individual's emotional and economic needs. This qualitative research study reviewed the workplace experiences and disclosure decisions of 18 HIV-positive individuals. The most frequently cited reasonsfor disclosing HIV status were to explain choices they were making as they interviewed for a job and concerns about their job performance and the needfor accommodations. For individuals who disclosed their HIV status to selective members of the workplace or disclosed to no one, the primary reasons given were preference for privacy, nature of the work environment, andfear of possible consequences. The practice, policy, and research implications for social workers are also discussed.

Adult↗
PubMed1996

[Informed consent in phase I trial].

Informed consent in phase I trials involves very difficult problems related to experimental factors of the phase I trial, a toxicity study conducted in human cancer patients. However, this is the first clinical step in new drug development, and patients must participate in phase I only when there is full disclosure of correct trial information. Disclosure should include the purpose of the trial, the procedure, and the risk/benefits related to the trial. Informing the patient of the cancer diagnosis and the extent of disease is also necessary before entry into a phase I trial. Although phase I trials are conducted with the precious contribution of patients, it is important that informed consent should not become a type of legal contract. Informed consent in phase I trials is an essential process, just like a roundtable discussion of patient and physician before fighting an incurable cancer.

Antineoplastic Agents↗
PubMed2000

Disclosure and prevention of medical errors. Committee on Bioethical Issues of the Medical Society of the State of New York.

Medical errors occur and are sometimes unavoidable. Physicians generally, but not always, have ethical and moral obligations to disclose their errors to the patient. Because common medical errors can be expected, physicians are obligated to work within health systems toward reducing systems flaws that promote errors. However, the obligations of physicians to disclose errors made by others are less clear. This article discusses the professional ethics involved in disclosing and preventing medical errors.

Ethics, Medical↗
PubMed2006

Disclosure of HIV status and adherence to daily drug regimens among HIV-infected children in Uganda.

Pediatric adherence to daily drug regimens has not been widely assessed in Africa where majority of HIV infected children live. Using in-depth interviews of 42 HIV-infected children taking ART and/or cotrimoxazole prophylaxis, and 42 primary caregivers, at a comprehensive HIV/AIDS clinic in Uganda, we evaluated their adherence experiences for purposes of program improvement. Daily drug regimens provided by the pediatric clinic included cotrimoxazole prophylaxis as well as ART and cotrimoxazole combined. Complete disclosure of HIV status by caregivers to children and strong parental relationships were related to good adherence. Structural factors including poverty and stigma were barriers to adherence even for children who had had complete disclosure and a supportive relationship with a parent. To ensure adherence to life-extending medications, our findings underscore the need for providers to support caregivers to disclose, provide on-going support and maintain open communication with HIV-infected children taking cotrimoxazole prophylaxis and ART.

AIDS-Related Opportunistic Infections↗